Diagnosis (Please be specific & provide as much information as possible):

Transcription

1 Please complete this entire form and fax it to: If you have questions, please call This form contains multiple pages. Please complete all pages to avoid a delay in our decision. Allow at least 24 hours for review. Section A Member Information First Name: Last Name: Member ID: Address: City: State: ZIP Code: Phone: DOB: Allergies: Primary Insurance: Policy #: Group #: Is the requested medication New or Continuation of Therapy? If continuation, list start date: Is this patient currently hospitalized? Yes No If recently discharged, list discharge date: Section B - Provider Information First Name: Last Name: M.D./D.O. Address: City: State: ZIP code: Phone: Fax: NPI #: Specialty: Office Contact Name / Fax attention to: Section C - Medical Information Medication: Strength: Directions for use: Diagnosis (Please be specific & provide as much information as possible): Quantity: ICD-10 CODE: Is this member pregnant? Yes No If yes, what is this member s due date? Section C Previous Section Medication D Previous Trials Medication Trials Medications Strength Directions Dates of Therapy Reason for failure / discontinuation Section E Additional information about this case, if any: I certify the information provided is true and accurate to the best of our knowledge and we understand that UnitedHealthcare may perform a routine audit and request the medical information necessary to verify the accuracy of the information provided. Prescriber s Signature: Date: Opioid overdose reversal medications are a covered benefit without prior authorization. CDC guidelines recommend offering naloxone to patients at increased risk of overdose, defined as: history of overdose or substance use disorder, doses > 50 MED/day, or concurrent use with benzodiazepines. Please refer to Preferred Drug Plan for preferred products.

2 Member First name: Member Last name: Member DOB: Clinical and Drug Specific Information 1. Requests for Non-Cancer/Non-Palliative Care/Non-Hospice/Non-Cancer Wean/LTC (Complete Section 3 also) ***Please fill out the Morphine Milligrams Equivalent Section of this form*** - What kind of pain is the medication being used to treat? Chronic moderate to severe pain Severe Post-operative pain - Does the patient require continuous around-the-clock analgesia therapy? Yes No - Has the patient tried any of the following non-opiate pain medication? (check all that apply) Baclofen NSAIDs (oral) Gabapentin Lidocaine 5% patch Duloxetine Capsaicin gel Tricyclic antidepressants - Does the patient have a history of contraindication, drug-drug interaction with, or toxic side effects that cause immediate or long-term damage from at least two of the following? Yes No (check all that apply, and complete Section D above with medication information) Morphine sulfate controlled release tablets (specifically generic MS Contin) Fentanyl transdermal (12, 25, 50, 75, and 100mcg) Butrans transdermal 2. Requests for Cancer/Palliative Care/Hospice/Cancer Wean/LTC - Does the patient meet any of the following? Yes No (check all that apply) Being treated for active cancer related pain (Date of Diagnosis: ) Receiving palliative care Receiving hospice care Established on pain therapy with the requested medication for cancer-related pain In remission from cancer and the prescriber is safely weaning patients off of opioids with a tapering plan In a Long Term Care (LTC) facility None - Does he patient have a diagnosis of breakthrough cancer pain? Yes No - Is the patient established on pain therapy with the requested medication for cancer-related pain or palliative care pain, and the medication is not a new regimen for treatment of the pain? Yes No If yes, list the date the regimen was started: - Does the patient have a history of contraindication, drug-drug interaction with, or toxic side effects that cause immediate or long-term damage from at least two of the following? Yes No (check all that apply, and complete Section D above with medication information) Yes No Morphine sulfate controlled release tablets (specifically generic MS Contin) Fentanyl transdermal (12, 25, 50, 75, and 100mcg) Butrans transdermal 3. Buprenorphine Plus Opioid/Morphine Milligram Equivalent - Does the prescriber attest to: there being extenuating circumstances necessitating the need to co-prescribe these medications, as well as, documentation provided of the tapering plan to achieve the lowest effective doses of these medications? Yes No List extenuating circumstances and taper plan: - What is the patient s total Morphine Milligrams Equivalents (MME) from the PMP website? (please refer to - What is the date of the patient s last opioid prescription from the PMP? - What is the date of the patient s last buprenorphine MAT prescription from the PMP? - What is the date of the patient s last benzodiazepine prescription from the PMP? - Has naloxone been prescribed for patients with risk factors of prior overdose, substance use disorder, or concomitant benzodiazepine use (in past 30 days)? Yes No Patient doesn t have any of the listed risks factors - Has naloxone been prescribed for the patient? Yes No

3 Member First name: Member Last name: Member DOB: - If patient is female between years old, has the prescriber discussed risk of becoming pregnant while receiving opioids, including the risk of Neonatal Opioid Withdrawal Syndrome/Neonatal Abstinence Syndrome and offered access to contraceptive services when necessary? Yes No - For chronic pain, does the prescriber attest that a treatment plan with goals that address benefits and harm has been established with the patient and there is a signed agreement with the patient? Yes No A sample Physician/Patient Agreement can be found at the following website: - Has the prescriber ordered and reviewed a urine drug screen (UDS) or serum medication level prior to initiating treatment with short or long-acting opioids? Yes No - Has the prescriber ordered and reviewed an urine drug screen (UDS) or serum medication level at least 3 months for the first year of treatment and at least every 6 months thereafter to ensure adherence? Yes No 4. Quantity Limit Requests Please note the plan s quantity limits: Opioid Conversion 90 MED Daily 120 MED FDA Label Max Dose per day Factor Equivalent Cumulative Limit Buprenorphine mcg/hr 67 mcg/hr 20mcg/hr Transdermal Buprenorphine Buccal mcg 4000 mcg 1,800mcg Butorphanol 7 13mg 17mg Codeine mg 800mg 360mg Hydrocodone 1 90mg 120mg Hydromorphone mg 30 mg Fentanyl Transdermal mcg/hr 50 mcg/hr Levorphanol tartrate 11 8mg 11mg Meperidine mg 1,200mg 600mg IR Products Morphine 1 90mg 120mg Oxycodone mg 80mg Xtampza Only = 288mg Oxymorphone 3 30mg 40 mg Pentazocine mg 324mg Tapentadol mg 300mg Tramadol mg 1,200mg 400mg IR products 300mg ER products Opium 1 90mg 120mg 4 suppositories/day Deordorized tincture: 24mg/day Camphorated tincture: 16mg/day - Can the requested dose be achieved by moving to a higher strength of the product? Yes No If yes, list reasoning for not switching: - Is there a reason why a greater quantity of medication is required to treat the patient s condition? Yes No If yes, list reason: - Does I attest the I requested will be managing dose exceed the patient s the FDA medically approved necessary limit or maximum opioid therapy Morphine long Equivalents term. I have per reviewed day (MED)? the Virginia BOM Regulations for Opioid Prescribing and acknowledge the warnings associated with high dose opioid therapy including fatal overdose and that therapy is medically necessary for this patient. Physician Signature: Date: Confidentiality Notice: This transmission contains confidential information belonging to the sender and UnitedHealthcare. This information is intended only for the use of UnitedHealthcare. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action involving the contents of this document is prohibited. If you have received this telecopy in error, please notify the sender immediately. Website:uhccommunityplan.com

4 Non-Opioid Treatment Options for Common Chronic Pain Conditions Non-invasive Low back pain treatment recommendations: i Acute (with or without radiculopathy): 1st Line (Non-pharmacologic): Keep in mind excellent natural history of disease. Acupuncture, massage, superficial heat shown to improve pain or function. Also consider pilates, tai-chi, yoga, psychology referral. 2nd Line (pharmacologic): NSAIDs, skeletal muscle relaxer Chronic (with or without radiculopathy): 1st Line (Non-pharmacologic): Exercise, motor control exercises, tai-chi, yoga, psychology referral, multidisciplinary rehabilitation, acupuncture, massage 2nd Line (pharmacologic): NSAIDs, duloxetine Post-herpetic neuralgia: ii Topical (1st line for mild pain): 5% lidocaine patch, capsaicin cream or patch Systemic: gabapentin, pregabalin*, amitriptyline, nortriptyline Diabetic neuropathy: iii 1st Line: pregabalin 2nd Line: gabapentin, venlafaxine (SNRI), duloxetine, amitriptyline (TCA), capsaicin 0.075% cream Fibromyalgia: iv Non-pharmacologic: Patient education (pertaining to lack of disease progression, lack of tissue damage), cognitive behavioral therapy (CBT), and cardiovascular exercise Pharmacologic: amitriptyline and cyclobenzaprine (TCAs), duloxetine (SNRI), gabapentin, pregabalin* (gabapentinoids), fluoxetine, sertraline, paroxetine (SSRIs) No evidence for use of opiates in fibromyalgia Migraines: v Acute Treatment Mild Moderate: acetaminophen, NSAIDs, caffeine, anti-emetics Severe: triptans, ergots, prochlorperazine, promethazine Preventative Treatment Propranolol, timolol, divalproex sodium, topiramate (Level A efficacy) Opiates can cause medication overuse headache Osteoarthritis: vi Non-pharmacologic: Exercise, weight loss, water-based exercise, wedged insoles, walking aides, splints Pharmacologic: Topical capsaicin, topical NSAIDs (preferred age > 75), oral NSAIDs (non-selective or COX-2 selective), intraarticular corticosteroid injection, consider duloxetine *Pregabalin requires a trial and failure of gabapentin or duloxetine iqaseem A, Wilt TJ, McLean RM, Forciea MA, for the Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166: doi: /M ii Johnson RW, Rice ASC. Clinical Practice: Postherpetic Neuralgia. N Engl J Med 2014;371: iii Griebeler ML, Morey-Vargas OL, Brito JP, Tsapas A, Wang Z, Carranza Leon BG, et al. Pharmacologic Interventions for Painful Diabetic Neuropathy: An Umbrella Systematic Review and Comparative Effectiveness Network Meta-analysis. Ann Intern Med. 2014;161: doi: /M Bril V, England J, Franklin GM, et al. Evidence-based guideline: Treatment of painful diabetic neuropathy: Report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2011;76(20): doi: /wnl.0b013e ebe. iv Clauw DJ. FibromyalgiaA Clinical Review. JAMA. 2014;311(15): doi: /jama v MacGregor EA. Migraine. Ann Intern Med. 2013;159:ITC5-1. doi: / vi Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken) Apr;64(4):465-74

5 Patient Utilization Management and Safety (PUMS) Program UnitedHealthcare Community Plan of Virginia has a Patient Utilization Management & Safety (PUMS) program in place. The program makes sure that members are getting the proper health care, especially when it comes to patient safety. PUMS Program Goal: PUMS deals with prescription drugs as well as other kinds of health care, making certain the member is getting treatment that is proper and safe. UnitedHealthcare Community Plan of Virginia s clinical staff reviews our members use of health care services to see whether they should be in the PUMS program. For members in the PUMS program, UnitedHealthcare Community Plan of Virginia takes extra steps to make sure they use services safely. Being considered for PUMS does NOT mean a member has done anything wrong. For any member who may be at risk for unsafe services, UnitedHealthcare Community Plan of Virginia must review whether the member should be in the PUMS program. In cases involving buprenorphine use, the member will automatically be in the PUMS program. How Might PUMS Change a Member s Care? UnitedHealthcare Community Plan of Virginia may offer case management services. UnitedHealthcare Community Plan of Virginia could set a single doctor for controlled substances to see the member, or a single pharmacy to provide controlled substance prescription drugs. PUMS Member Rights: UnitedHealthcare Community Plan of Virginia will send every PUMS member a letter about the program. The letter will make clear how the member can get emergency care. The letter will also tell them how they can appeal being placed in the PUMS program. PLEASE NOTE: UnitedHealthcare Community Plan of Virginia doctors and pharmacists now use the Prescription Monitoring Program (PMP). The PMP helps them make sure that prescription drugs are used safely. Among other Patient Utilization Management & Safety (PUMS) triggers we review patients who have: High Average Daily Dose: > 120 cumulative morphine milligram equivalents (MME) per day over the past 90 days. And/or Concurrent use of Opioids and Benzodiazepines at least 1 Opioid claim and 14 day supply of Benzo (in any order) Our approach is to work collaboratively with patients and providers to ensure safe and appropriate use of controlled substances. We utilize and promote: A) PMP Checks B) Letter to Doctor & Member C) Soft and Hard Pharmacy edits for Benzodiazepine and Opioid utilization D) Following CDC Opioid Guidelines E) Case Management as appropriate We greatly appreciate your collaboration and UnitedHealthcare Community Plan of Virginia service to our members. As part of our PUMS safety review we hope to collaborate with you for complete patient information with the goal of validating safe and appropriate controlled substance use and coordinated patient care. RESPECTFULLY, UnitedHealthcare Community Plan of Virginia CLINICAL STAFF