Drug Name (specify drug) Quantity Frequency Strength

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Drug Name (specify drug) Quantity Frequency Strength

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2. Is this request for a preferred medication? Y N

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

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Transcription:

Prior Authorization Form MEDICA HEALTH PLAN IA EXCHANGE 1362-M Opioids IR Labeling Post Limit (HMF) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to CVS/Caremark at 1-855-245-2134. Please contact CVS/Caremark at 1-855-582-2022 with questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of 1362-M Opioids IR Labeling Post Limit (HMF). Drug Name (specify drug) Quantity Frequency Strength Route of Administration Expected Length of Therapy Patient Information Patient Name: Patient ID: Patient Group No.: Patient DOB: Patient Phone: Prescribing Physician Physician Name: Physician Phone: Physician Fax: Physician Address: City, State, Zip: Diagnosis: ICD Code: Comments: Please circle the appropriate answer for each question. 1. Is the requested drug being prescribed for pain associated with cancer, a terminal condition, or pain being managed through hospice or palliative care? [If yes, then no further questions.] 2. Can the patient safely take the requested dose based on their history of opioid use? 3. Has the patient been evaluated and will the patient be monitored regularly for the development of opioid use disorder?

4. Is the requested drug being prescribed for moderate to severe CHRONIC pain where use of an opioid analgesic is appropriate? [Note: Chronic pain is generally defined as pain that typically lasts greater than 3 months.] [If no, then skip to question 6.] 5. Will the patient's pain be reassessed in the first month after the initial prescription or any dose increase AND every 3 months thereafter to ensure that clinically meaningful improvement in pain and function outweigh risks to patient safety? [If yes, then skip to question 7.] [If no, then no further questions.] 6. Is the requested drug being prescribed for moderate to severe ACUTE pain where use of an opioid analgesic is appropriate? [If yes, then skip to question 8.] [If no, then no further questions.] 7. Which drug is being requested (applies to brand or generic)? [Note: Please check which drug (applies to brand or generic).] codeine sulfate oral solution or tablets (if checked, go to 9) hydromorphone oral liquid, suppositories, tablets (if checked, go to 10) levorphanol tablets (if checked, go to 11) meperidine oral solution and tablets (if checked, go to 12) morphine sulfate oral concentrate or oral solution (if checked, go to 13) morphine sulfate suppositories (if checked, go to question 14) morphine sulfate tablets (if checked, go to question 15) oxycodone, Oxaydo, or RoxyBond capsules or tablets (if checked, go to question 16) oxycodone oral concentrate or oral solution (if checked, go to 17) oxymorphone tablets (if checked, go to question 18) pentazocine/naloxone tablets (if checked, go to 19) tapentadol tablets (Nucynta) (if checked, go to 20) tramadol tablets (if checked, go to 21) 8. Which drug is being requested (applies to brand or generic)?

[Note: Please check which drug (applies to brand or generic).] codeine sulfate oral solution or tablets (if checked, go to 22) hydromorphone oral liquid, suppositories, tablets (if checked, go to 23) levorphanol tablets (if checked, go to 24) meperidine oral solution and tablets (if checked, go to 25) morphine sulfate oral concentrate or oral solution (if checked, go to 26) morphine sulfate suppositories (if checked, go to question 27) morphine sulfate tablets (if checked, go to question 28) oxycodone, Oxaydo, or RoxyBond capsules or tablets (if checked, go to question 29) oxycodone oral concentrate or oral solution (if checked, go to 30) oxymorphone tablets (if checked, go to question 31) pentazocine/naloxone tablets (if checked, go to 32) tapentadol tablets (Nucynta) (if checked, go to 33) tramadol tablets (if checked, go to 34) 9. Does the patient require use of MORE than 840 ml/month of codeine sulfate oral solution OR MORE than 84 tablets/month of codeine sulfate tablets? 10. Does the patient require use of MORE than any of the following: A) 1800 ml/month of hydromorphone liquid, B) 180 hydromorphone suppositories/month, C) 270 hydromorphone tablets per month? 11. Does the patient require use of MORE than 180 levorphanol tablets/month? 12. Does the patient require use of MORE than 120 ml/month of meperidine oral solution OR MORE than 24 tablets/month of meperidine tablets? 13. Does the patient require use of MORE than 270 ml/month of morphine sulfate oral concentrate solution OR MORE than 1350 ml/month of morphine sulfate oral solution?

14. Does the patient require use of MORE than 270 morphine sulfate suppositories/month? 15. Does the patient require use of MORE than 270 morphine sulfate tablets/month? 16. Does the patient require use of MORE than any of the following: A) 270 capsules or tablets/month of generic oxycodone (any strength) or RoxyBond 15 mg, 30 mg, B) 810 tablets/month of Oxaydo 5 mg or RoxyBond 5 mg, C) 540 tablets/month of Oxaydo 7.5 mg? 17. Does the patient require use of MORE than 270 ml/month of oxycodone oral concentrate 100 mg/5 ml (20 mg/ml) OR MORE than 2700 ml/month of oxycodone oral solution 5 mg/5 ml? 18. Does the patient require use of MORE than 360 oxymorphone tablets/month? 19. Does the patient require use of MORE than 360 pentazocine/naloxone tablets/month? 20. Does the patient require use of MORE than any of the following: A) 390 tablets/month of Nucynta (tapentadol) 50 mg, B) 270 tablets/month of Nucynta (tapentadol) 75 mg, C) 210 tablets/month of Nucynta (tapentadol) 100 mg? 21. Does the patient require use of MORE than 240 tablets/month of tramadol? 22. Does the patient require use of MORE than 840 ml/month of codeine sulfate oral solution OR MORE than 84 tablets/month of codeine sulfate tablets? 23. Does the patient require use of MORE than any of the following: A) 1800 ml/month of hydromorphone liquid, B) 180 hydromorphone suppositories/month, C) 270 hydromorphone tablets/month? 24. Does the patient require use of MORE than 180 levorphanol tablets/month?

25. Does the patient require use of MORE than 120 ml/month of meperidine oral solution OR MORE than 24 tablets/month of meperidine tablets? 26. Does the patient require use of MORE than 270 ml/month of morphine sulfate oral concentrate solution OR MORE than 1350 ml/month of morphine sulfate oral solution? 27. Does the patient require use of MORE than 270 morphine sulfate suppositories/month? 28. Does the patient require use of MORE than 270 morphine sulfate tablets/month? 29. Does the patient require use of MORE than any of the following: A) 270 capsules or tablets/month of generic oxycodone (any strength) or RoxyBond 15 mg, 30 mg, B) 810 tablets/month of Oxaydo 5 mg or RoxyBond 5 mg, C) 540 tablets/month of Oxaydo 7.5 mg? 30. Does the patient require use of MORE than 270 ml/month of oxycodone oral concentrate 100 mg/5 ml (20 mg/ml) OR MORE than 2700 ml/month of oxycodone oral solution 5 mg/5 ml? 31. Does the patient require use of MORE than 360 oxymorphone tablets/month? 32. Does the patient require use of MORE than 360 pentazocine/naloxone tablets/month? 33. Does the patient require use of MORE than any of the following: A) 390 tablets/month of Nucynta (tapentadol) 50 mg, B) 270 tablets/month of Nucynta (tapentadol) 75 mg, C) 210 tablets/month of Nucynta (tapentadol) 100 mg? 34. Does the patient require use of MORE than 240 tablets/month of tramadol? I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature and Date

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