Oxycodone Controlled-Release (Oxycontin) - Medical Necessity Request Form Page 2

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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: __________________
**Complete page 2 only for Subsequent/Renewal requests**
1. What was the previous dose? ________________________________________
□ Yes
2. Will the previous dose be discontinued?
□ No - will be taking in addition to new dose
□ No - Same as previous dose
3. What is the new, total dose of OxyContin that the member will be receiving (include any other
strengths of OxyContin that the member will also be receiving)? ____________________
________________________________________________________________________________________
4. 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)
5.
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?
_______________________________________________________________
6. 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
2 of 2
Rev. 03/16
HNJH Fax #: 888-567-0681
Page

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