Nebraska Medicaid Program Request For Prior Authorization Buprenorphine/naloxone And Buprenorphine Form

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NEBRASKA MEDICAID PROGRAM REQUEST FOR PRIOR AUTHORIZATION
BUPRENORPHINE/NALOXONE AND BUPRENORPHINE
PRESCRIBING PHYSICIAN:
MEDICAID RECIPIENT:
Name: _________________________________
Name: _________________________________
First
Last
First
Last
Phone #:
-
-
Medicaid #:
/
/
Fax #:
-
-
Date of Birth:
NPI
(NOTE: Patient must be 18 years or older.)
DEA X
Male
Female
/
/
DEA X# Exp
PARTICIPATING PHARMACY:
Name: ________________________________
Request Date: __________________________
Phone #:
-
-
Fax #:
-
-
Strength:
Qty Per Day:
Maximum Duration of
Buprenorphine/ Naloxone
Treatment:
Buprenorphine
(circle one)
12 months
Zubsolv®
Diagnosis confirmed as treatment of Opioid Use Disorder and not pain management:
Yes
No
**ABOVE PRODUCTS ARE NOT COVERED FOR PAIN MANAGEMENT**
INITIAL REQUEST
RENEWAL REQUEST
1) Prescriber has been issued an “X” DEA license number to prescribe?
Yes
No
2) Does the patient have other opioid (including tramadol) medications
Yes
No
prescribed at time of buprenorphine initiation? (must be discontinued for
authorization)
3) Is the patient receiving ancillary services, such as psychosocial therapy from
Yes
No
an Adult Substance Abuse provider & how often are they to be seen?
Who is providing services?
Provider: __________________________ Provider type: ______________________
Phone #: __________________________
4) Has the patient signed a contract (or Informed Consent) and committed to
Yes
No
both pharmacologic and non-pharmacologic modalities of treatment? (attach
either clinic standard form or Nebraska form)
5) Planned length of treatment and tapering schedule?
(maximum duration of treatment 12 months)
6) Is this the first time the patient has been treated with buprenorphine?
Yes
If no, ______________________________________________________
No,
Prescriber must provide
documentation of current factors which
___________________________________________________________
indicate treatment will be successful.
Yes
No
7) Is patient pregnant or nursing? Expected delivery date ________________
8) For renewal:
Yes
No
Has patient been compliant with all schedules and had appropriate random
urine drug screening results? (attach quantitative laboratory results)
Submit requests to: Magellan Medicaid Administration, Inc.
Fax: 1-866-759-4115
Tel: 1-800-241-8335
Rev. February 2014

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