3. Has the patient had a sustained improvement in Pain or Function (e.g. PEG scale with a 30 percent response from baseline)?

Transcription

1 Pharmacy Prior Authorization AETA BETTER HEALTH KETUCK Opioids Long-Acting and Short-Acting (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to Aetna Better Health Kentucky at When conditions are met, we will authorize the coverage of Opioids Long-Acting and Short-Acting (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame Specify drug Quantity Frequency Strength Route of administration Patient information Patient name: Patient ID: Patient Group o.: Patient DOB: Patient phone: Prescribing physician Expected length of therapy Physician name: Specialty: PI number: Physician fax: Physician phone: Physician address: City, state, zip: Diagnosis: ICD Code: the appropriate answer for each question. Question 1. Does the patient have pain due to active cancer, palliative care, or end-of-life care? [If yes, then no further questions.] 2. Has Aetna Better Health authorized this medication in the past for this patient (i.e., previous authorization is on file under this plan)? [If no, then skip to question 15.] 3. Has the patient had a sustained improvement in Pain or Function (e.g. PEG scale with a 30 percent response from baseline)? Reference umber: C7187 A / Effective Date: 02/01/2018 1

2 [If yes, then skip to question 5.] 4. Has a tapering plan been initiated to discontinue treatment? 5. Will a urine drug screen (UDS) be performed at least annually? 6. Has the prescriber reviewed and verified the state Prescription Monitoring Program (PMP) database for prescriptions from other providers, benzodiazepines use, or ER/LA for acute pain? 7. Is the calculated MED (Morphine Equivalent Dosing) dosage greater than 50 MED per day? [If no, then skip to question 11.] 8. Has the provider offered aloxone to the patient? ote: aloxone is available on the formulary without Prior Authorization. 9. Is the calculated MED (Morphine Equivalent Dosing) dosage greater than 90 MED per day? [If no, then skip to question 11.] 10. Is the requested drug being prescribed by or in consultation with a Pain specialist? 11. Is the patient taking the opioid with benzodiazepines? [If no, then skip to question 13.] 12. Has the provider counseled the patient on the FDA black box warning on the dangers of prescribing opioids in combination with benzodiazepines and will prescribe at the lowest effective dosage and duration? Reference umber: C7187 A / Effective Date: 02/01/2018 2

3 13. Is this request for the treatment of chronic pain? [If yes, then no further questions.] 14. Is this request for the treatment of acute pain? [o further questions.] 15. Does the patient have a treatment plan that includes the goals for pain and function (e.g., pain may still persist while function has improved) and when treatment will be stopped? 16. Does the treatment plan address the following: A) Consequences of lost medication, B) Consequences of obtaining controlled substances from other prescribers, C) An agreement with the patient to only use one pharmacy? 17. Will the treatment plan be reviewed within 1 to 4 weeks of starting opioid therapy for chronic pain and with any dose escalation and reevaluated every 3 months? Please submit a signed treatment plan along with a completed Opioid PA form. 18. Will the prescriber address harm and benefits before treatment and periodically during treatment (i.e., increased risks of respiratory depression, combination use with benzodiazepines, risks to other household members including children, cognitive limitations, and side effects)? 19. Will the treatment be prescribed at the lowest effective dose? 20. Has the prescriber reviewed the state Prescription Monitoring Program (PMP) database for opioid over dosages or dangerous combinations? 21. Has a urine drug screen (UDS) or serum medication level been reviewed prior to initiating treatment with short acting opioids and/or Reference umber: C7187 A / Effective Date: 02/01/2018 3

4 long acting opioids? 22. Does the patient have risk factors of prior overdose, substance use disorder, doses in excess of 90 MED (Morphine Equivalent Dosing) per day or concomitant benzodiazepines use? [If no, then skip to question 24.] 23. Has a prescription for naloxone been offered to the patient or the patient s household? 24. Does the patient have evidence of Substance use Disorder? [If no, then skip to question 26.] 25. Will the prescriber offer or arrange for evidence based treatment where needed? 26. Is the patient female of reproductive age? [If no, then skip to question 28.] 27. Has the patient been counseled about opioid use during pregnancy and neonatal abstinence syndrome (AS)? 28. Is this request for a Short-Acting Opioid? [If no, then skip to question 35.] 29. Is this request for a on-formulary agent? [If no, then skip to question 31.] 30. Has the patient had an inadequate response or intolerance to at least TWO other formulary short-acting opioids? 31. Is this request for more than any of the following: A) 90 MED (Morphine Equivalent Dosing) per day, B) 7 Day Supply for patients 18 years of age or older, C) 3 Day Supply for patients less than 18 years Reference umber: C7187 A / Effective Date: 02/01/2018 4

5 of age? [If no, then skip to question 33.] 32. Has support for the medical necessity of exceeding the recommended MED or day supply limit been documented? If yes, then please provide documentation to support the medical necessity of exceeding the recommended MED or day supply limit: 33. Is this request for the treatment of acute pain? [If no, then skip to question 42.] 34. Is this request for an MED (Morphine Equivalent Dosing) greater than 200 per day? [o further questions.] 35. Has the provider initiated treatment with an immediate release opioid for at least 2 weeks before considering Extended release/long acting opioids? ote: Use should be reserved for severe, continuous pain and not for intermittent use. 36. Is this request for more than 90 MED (Morphine Equivalent Dosing) per day? [If no, then skip to questions 38.] 37. Has support for the medical necessity of exceeding the recommended MED or day supply limit been documented? If yes, then please provide documentation to support the medical necessity of exceeding the recommended MED or day supply limit: 38. Is this request for one of the following medications: fentanyl patch, morphine sulfate ER, or methadone? [If yes, then skip to question 42.] Reference umber: C7187 A / Effective Date: 02/01/2018 5

6 39. Has the patient experienced an inadequate response or intolerance to trials of at least 2 weeks each of at least TWO formulary long-acting opioids (i.e., fentanyl patch, morphine sulfate ER, methadone)? Please list medications tried and reason for treatment failure: 40. Is this request for oxymorphone ER? [If yes, then skip to question 42.] 41. Has the patient experienced an inadequate response or intolerance to a trial of at least 2 weeks of oxymorphone ER? 42. Is this request for the treatment of chronic pain? 43. Have non-pharmacologic therapy (e.g. physical therapy, exercise, Cognitive Behavioral Therapy, weight loss) and non-opioid therapy (e.g. topical diclofenac, SAIDs, TCAs, and SRIs, or anticonvulsants) been tried before prescribing opioids? 44. Is this request for an MED (Morphine Equivalent Dosing) greater than 200 per day? Comments: I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature Prescriber (Or Authorized) Signature Date Date Reference umber: C7187 A / Effective Date: 02/01/2018 6