Oral And Intranasal Fentanyl Citrate Products (Actiq, Fentora, Onsolis, Abstral, Lazanda, Subsys) Medical Necessity Request Form

ADVERTISEMENT

Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
Horizon NJ Health
Oral and Intranasal Fentanyl Citrate Products (Actiq, Fentora, Onsolis, Abstral, Lazanda, Subsys)
Medical Necessity Request
1. Is the medication being used for the management of acute or postoperative pain, including headache/migraine
and dental pain? Yes or No
2. Is the member being managed by an Oncologist or Pain Management specialist? Yes or No
3. What is the diagnosis?
□ Cancer
a. Is the member currently receiving around-the-clock opioid therapy (e.g., OxyContin, Morphine
sulfate extendered relesase, Fentanyl patch, etc) for their underlying persistent cancer pain?
□ No
□ Yes - Please provide the name, dosage, directions, and quantity of the opioid(s) the
member has most recently received and the date last received.
Drug Name
Strength
Directions
Quantity
Date last received
□ Other: _____________________
a. Is the member already receiving opioid therapy (e.g., Oxycodone/APAP, hydrocodone,
Oxycontin, Morphine, etc)?
□ No
□ Yes - Please provide the name, dosage, directions, and quantity of the opioid(s) the
member has most recently received and the date last received.
Drug Name
Strength
Directions
Quantity
Date last received
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office
1 of 1
Rev. 03/16
HNJH Fax #: 888-567-0681
Page

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Fentanyl Transdermal System (duragesic) - Medical Necessity Request Form Fentanyl Transdermal System (duragesic) - Medical Necessity Request Form Medical
Medical Necessity Request Form Medical Necessity Request Form Medical
Medical Necessity Request Form Medical Necessity Request Form Medical
Medical Necessity Request Form Medical Necessity Request Form Medical
Medical Necessity Request Form Medical Necessity Request Form Medical
Pimecrolimus (elidel) And Tacrolimus (protopic) - Medical Necessity Request Form Pimecrolimus (elidel) And Tacrolimus (protopic) - Medical Necessity Request Form Medical
Epoetin Alfa And Darbepoetin Alfa - Medical Necessity Request Form Epoetin Alfa And Darbepoetin Alfa - Medical Necessity Request Form Medical
Hemophilia Medications - Medical Necessity Request Form Hemophilia Medications - Medical Necessity Request Form Medical
Ezetimibe (zetia) - Medical Necessity Request Form Ezetimibe (zetia) - Medical Necessity Request Form Medical
Growth Hormone (gh) Therapy - Medical Necessity Request Form Growth Hormone (gh) Therapy - Medical Necessity Request Form Medical

Related Categories

Parent category: Medical
Download
Go