Oxycodone Controlled-Release (Oxycontin) - 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
Oxycodone Controlled-Release (OxyContin) – Medical Necessity Request
**Please complete page 1 for New/Initial requests**
1. Please indicate if the member has any of the following contraindications:
□ Significant respiratory depression
□ Acute or severe bronchial asthma
□ Has or is suspected of having paralytic ileus
□ NONE
2. What is the diagnosis?
□ Pain
- What is the severity of the pain? □ Mild
□ Moderate
□ Severe
□ Other: _________________________________________
3. Is continuous analgesia for an extended period of time (e.g. >6 months) needed? Yes or No
4. Is the member opioid naive? (i.e. never used opioid analgesics in the recent past?) [NOTE: Examples of opioids are
OxyContin, Avinza, MS Contin, Kadian, Oramorph, Duragesic/Fentanyl, Opana, Percocet, or Vicodin] Yes or No
is the dose for 10 mg twice a day?
- If Yes,
Yes or No
- If No (the dose is not for 10 mg twice a day), would the physician consider changing the dose to 10mg
twice a day? Yes or No
- If No, please provide the clinical reason why the dose cannot be changed to 10mg twice daily for a
member who is opioid naïve:
_______________________________________________________________________
5. What opioid therapy is the member currently receiving and when was it last received? (include dose, directions and fill
dates)
_____________________________________________________________________________________________________
6. Will the member be taking any other strengths of Oxycontin concurrently with this strength? Yes or No
- If Yes, list the other strength and dosing directions of OxyContin that the member will be receiving.
______________________________________________________________________________________________
7. Is OxyContin being prescribed:
□ on a scheduled basis (patient will be taking Oxycontin on a set schedule)
□ on an as needed (prn) basis (patient can take any time (s)he is in pain)
8. Is the member on any other long-acting opioid pain controller? (i.e. OxyContin, Avinza, MS Contin, Kadian, Oramorph,
Duragesic/Fentanyl, or Butrans) Yes or No
- If Yes, Which long-acting opioid pain controller(s) is the member receiving? _________________________
- 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 Oxycontin
is approved (include date drug was discontinued)?
_______________________________________________________________________________________
9. Will all the OxyContin prescriptions be coordinated by a single provider's office? Yes or No
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office
1 of 2
Rev. 03/16
HNJH Fax #: 888-567-0681
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