Short-Acting Opioid Analgesics - Prior Authorization Form

Office of Medical Assistance Programs

Fee-for-Service, Pharmacy Division

Phone 1-800-537-8862 Fax 1-866-327-0191

SHORT-ACTING OPIOID ANALGESICS

PRIOR AUTHORIZATION FORM

Prior authorization & quantity limit guidelines are on the Pharmacy Services website:

PRIOR AUTHORIZATION REQUEST INFORMATION

PRESCRIBER INFORMATION

New request

Renewal request

Total # pages: ___________

Prescriber name:

Name/phone of

Specialty:

office contact:

LTC facility

NPI:

State license:

contact/phone:

RECIPIENT INFORMATION

Street address:

Recipient Name:

Suite #:

City/state/zip:

Recipient ID#:

DOB:

Phone:

Fax:

CLINICAL INFORMATION

Drug:

Strength

Quantity per fill

_____ to last ____ days

:

:

Directions

Total fills requested (from 1-12): _______

:

Diagnosis

Diagnosis code

(submit documentation):

(required):

Weight (if <21 yrs):

_________

1.

Did the prescriber or prescriber’s delegate search the PDMP to review the recipient’s controlled

Yes

Submit documentation.

substance prescription history before issuing this prescription for the requested agent?

No

2.

Is the recipient taking a benzodiazepine? Submit recipient’s current medication list.

Yes – list: _______________________

No

3.

Initial requests for all non-preferred medications: Does the recipient have a history of trial and

failure of or contraindication or intolerance to the following preferred short-acting opioid analgesics?

Submit documentation of

Check all that apply.

Yes

trial & failure,

APAP/codeine tablet or elixir

morphine IR tablet

oxycodone/APAP tablet

No

contraindications, or

intolerances.

hydrocodone/APAP tablet

morphine solution or concentrate

tramadol IR tablet

hydrocodone/ibuprofen tablet

oxycodone IR tablet

4.

What is the anticipated duration of therapy with opioid analgesics?

Specify duration: ______________________

Submit documentation.

5.

Check all of the following that apply to the Recipient. Submit detailed medical record documentation for EACH item.

INITIAL requests:

has documentation of a complete physical exam, including diagnostic testing/imaging results, and pain assessment (cause, severity, location, etc)

has tried or cannot try non-drug pain management modalities (eg, behavioral, cognitive, physical, and/or supportive therapies)

has tried or cannot try non-opioid drugs for the treatment of pain – check drugs tried:

acetaminophen

NSAIDs

other: _______________

the requested opioid medication will be used in combination with tolerated non-drug therapies and non-opioid medications

was assessed for the potential risk of misuse, abuse, and addiction based on family and social history obtained by prescriber

was counseled regarding potential side effects of opioids including risk of misuse, abuse, addiction (if <21 yo, parent/guardian may be counseled)

was assessed for recent (within the past 60 days) opioid use

was evaluated for risk factors for opioid-related harm

if identified to be at high risk for opioid-related harm, the prescriber considered prescribing naloxone

has a recent UDS testing for illicit and licit substances of abuse (with specific testing for oxycodone, fentanyl, tramadol, and carisoprodol)

RENEWAL requests:

experienced an improvement in pain control and level of functioning while on the requested agent

the requested opioid medication will be used in combination with tolerated non-drug therapies and non-opioid medications

is being monitored by the prescriber for adverse events and warning signs of serious problems, such as overdose and opioid use disorder

was evaluated for risk factors for opioid-related harm

if identified to be at high risk for opioid-related harm, the prescriber considered prescribing naloxone

has a recent UDS testing for illicit and licit substances of abuse (with specific testing for oxycodone, fentanyl, tramadol, and carisoprodol)

6.

For requests for oral fentanyl products (eg, Abstral, Actiq, Fentora, Subsys), submit documentation that the recipient is opioid-tolerant and

has a diagnosis of cancer.

7.

For requests for nasal butorphanol (Stadol), check all of the following that apply to the recipient. Submit documentation for EACH item.

the recipient is opioid-tolerant (names and dosages of current opioid regimen)

if being treated for migraine, has a history of trial & failure of or contraindication or intolerance to abortive (triptans) & preventive medications

PLEASE FAX COMPLETED FORM WITH REQUIRED CLINICAL DOCUMENTATION TO DHS – PHARMACY DIVISION

Prescriber Signature:

Date:

Confidentiality Notice: The documents accompanying this telecopy may contain confidential information belonging to the sender. The information is intended only for the use of the individual

named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or taking of any telecopy is strictly prohibited.

Form effective 7/25/17