Fentanyl Transdermal System (Duragesic) - Medical Necessity Request Form
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2Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
Horizon NJ Health
Fentanyl Transdermal System (Duragesic) – Medical Necessity Request
Contraindication Information (please indicate if the member has any of the following contraindications):
□ Needs opioid pain relief for a short period of time
□ Significant respiratory compromise
- Is adequate monitoring and resuscitative equipment
□ Receiving the Duragesic patch for post-operative pain
readily available? Yes or No
□ Intermittent pain (i.e., use on an as needed (prn) basis)
□ Acute or severe bronchial asthma
□ Known or suspected paralytic ileus
□ NONE
General Information
1.
What is the diagnosis?
□ Pain
□ Other: ____________________
2.
Is the pain persistent? Yes or No
3.
Is the pain chronic? Yes or No
4.
What is the pain severity?
□ Mild
□ Moderate
□ Severe
5.
Is the member currently or will the member be on any other long-acting opioid pain controller together with the Fentanyl patch?
(i.e. OxyContin, Avinza, MS Contin, Kadian, Oramorph, Duragesic/Fentanyl, Opana ER, Butrans) Yes or No
-
If yes, which long-acting opioid pain controller(s) will the member be receiving concurrently?
_____________________________________________________________________________________
-
What is the clinical reason why the member is receiving more than one long-acting opioid pain controller?
_______________________________________________________________________________________
-
Please document any long-acting opioids that have recently been discontinued or will be discontinued if fentanyl is
approved (include date drug was discontinued)?
_______________________________________________________________________________________
6.
Is the member already receiving opioid therapy? (NOTE: Examples of opioids are OxyContin, Avinza, MS Contin, Kadian,
Oramorph, Duragesic/Fentanyl, Opana, Percocet, or Vicodin) Yes or No
-
What opioid therapy is the member currently receiving and when was therapy last received? (dose, frequency, day
supply, and date of last fill)
______________________________________________________________________________________
□ every 72 hours
□ Other: _______________
7.
How often will the Duragesic patch be applied?
□ every 48 hours:
- Has the member tried an every 72-hours regimen?
□ Yes: Was adequate pain control was achieved using a 72-hour regimen at the requested strength?
□ Yes: Please provide the reason for requesting an every 48 hour regimen if adequate pain
control was achieved using a 72-hour regimen.
________________________________________________________________________
□ No
□ No: Can the member try an every 72 hours regimen?
□ Yes
□ No: Please provide the clinical reason why the member cannot try an every 72 hour
regimen. ____________________________________________________________
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office
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Rev. 03/16
HNJH Fax #: 888-567-0681
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