Methadone - Medical Necessity Request Form

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Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
Horizon NJ Health
Methadone – Medical Necessity Request
Contraindication Information (please indicate if the member has any of the following contraindications to therapy):
□ Acute bronchial asthma
□ Hypercarbia
□ Known or suspected paralytic ileus
□ Respiratory depression
□ NONE
Diagnosis Information (please indicate diagnosis and answer related questions):
□ Pain
- What is the severity of the member’s pain?
□ Mild
□ Moderate
□ Severe
□ Restless Leg Syndrome (RLS)
1. Has the member tried and failed ropinirole (generic Requip) and/or pramipexole (generic Mirapex)?
□ Yes - Ropinirole (generic Requip)
Can the member try Pramipexole (Mirapex)?
□ Yes - please call the new prescription in to the pharmacy.
□ No – please provide the clinical reason why pramipexole cannot
be tried: ____________________________________________________
□ Yes - Pramipexole (generic Mirapex)
Can the member try Ropinirole (Requip)?
□ Yes - please call the new prescription in to the pharmacy.
□ No – please provide the clinical reason why ropinirole cannot
be tried: ____________________________________________________
□ Yes - Both Ropinirole (Requip) and Pramipexole (Mirapex)
□ Neither - Can the member try ropinirole (generic Requip) and/or pramipexole (generic Mirapex)?
□ Yes – please call the new prescription in to the pharmacy.
□ No – please provide the clinical reason why one of the alternatives cannot be tried:
___________________________________________________________________
□ Opioid Addiction – Methadone is covered through NJ State Medicaid for the diagnosis of opioid addiction. Please contact
NJ State Medicaid. Note, for MLTSS members it is covered under the HNJH medical benefit via Methadone clinics.
□ Other: __________________________________________________________
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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