Read General/Non-Preferred Drug Prior Authorization Form text version

Prior Authorization Form Long Acting Narcotics
***All PA forms may be found by accessing https://tnm.providerportal.sxc.com/rxclaim/TNM/PAs.htm.***
If the following information is not complete, correct, or legible the PA process can be delayed. Use one form per member please.
Member Information
Last Name ID Number First Name Date of Birth
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Prescriber Information
Last Name Office Address City NPI# Phone State DEA# Zip First Name
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Fax
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Requested Long-Acting Narcotic
**PREFERRED** Kadian® morphine sulfate SA Opana ER® oxymorphone SR Avinza® Butrans® Dolophine® Duragesic® Strength___________ EmbedaTM ExalgoTM fentanyl patch methadone Non-Preferred Methadose® morphine sulfate SR 24 hour Nucynta® ER Oramorph® SR Quantity Requested_____________ oxycodone SR Oxycontin®
Directions _______________________________________________ Yes No
Request to Backdate PA? TOTAL DAILY DOSE:
If Yes, Requested PA Start Date____________________
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*** If requesting a total daily dose exceeding the threshold listed in the tables below, complete Questions 1-11 under Clinical Criteria Documentation. Otherwise, complete Questions 1-7, then skip to the Authorized Prescriber Signature section at the bottom of the form.
Drug
Avinza® Duragesic® / fentanyl patch EmbedaTM Kadian®/morphine sulfate SR 24 hr methadone /Methadose®
Daily Dosage Threshold
180 mg/day 75 mcg/hr: 10 patches per month - OR100 mcg/hr: 10 patches per month 200 mg/day morphine component 200 mg/day 40 mg/day
Drug
morphine sulfate SA MS Contin® Nucynta® ER Opana® ER/ oxymorphone SR Oramorph® SR oxycodone SR Oxycontin®
Daily Dosage Threshold
200 mg/day 200 mg/day 500 mg/day 80 mg/day 200 mg/day 160 mg/day 160 mg/day
Clinical Criteria Documentation 1. Diagnosis (please check all that apply): Cancer pain Chronic back pain 2. Sickle cell disease Fibromyalgia
****Do not include documentation that is not requested on this form**** HIV/AIDS Hospice patient Other____________________________________ (specify and list ICD-9)
Initial date of diagnosis: _________________________ Provide details for patient's history of opioid use:
Date narcotics initiated for diagnosis: ___________________________
Drug 1:_________________________ Strength: _______________ SIG: ______________________ Dates: _________________ Reason for discontinuation of the drug: __________________________________________________________________________ Drug 2:_________________________ Strength: _______________ SIG: ______________________ Dates: _________________ Reason for discontinuation of the drug: __________________________________________________________________________ Drug 3:_________________________ Strength: _______________ SIG: ______________________ Dates: _________________ Reason for discontinuation of the drug: __________________________________________________________________________
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TennCare Prior Authorization Form: Long-Acting Narcotics ­ Page 2 ­
Patient Name:_____________________________________ 3. 4. 5. Does the patient have inability to swallow or absorb PO medications? Will this request be utilized for a dose titration? Yes No Yes No Yes No DOB_______________
Has the patient been on another long acting-acting narcotic within the last 30 days? If yes, has this medication been discontinued? Yes
No (please provide reason) _________________________________
___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ 6. Does this patient exhibit any of the following characteristics or behaviors? History of addiction to the requested drug Frequent reports of lost or stolen tablets History of parenteral substance abuse Yes (check all that apply) No
Frequent requests for early refills
Frequent requests for odd quantities
Requests for short term or PRN use of long-acting narcotics Evidence of diversion
Please explain any of the above check boxes: ______________________________________________________________________ ___________________________________________________________________________________________________________ 7. 8. 9. Document most recent date the provider checked the Tennessee Controlled Substance Database for this patient: _______________ Is the patient currently a resident in a long term care facility? Yes No If Yes, name of facility: _______________________________________________________________________________________ For Butrans requests only: What is the proposed tapering schedule for other opioid analgesics prior to initiation of Butrans? _________________________________________________________________________________________ __________________________________________________________________________________________________________ ***Requests for Total Daily Doses below the threshold in Table 2 may now skip to the Prescriber Signature section at the bottom of this page. All other requests must complete Questions 10-13. Narcotic Monitoring Information 10. Has a written medical treatment plan with stated objectives consistent with Board of Medical Examiner's rule 0880-2-.14 Yes No (website: http://www.tn.gov/sos/rules ) been established? 11. Has a Patient Controlled Substance Agreement been initiated for this patient? If yes, will this agreement be re-evaluated every 6 months? Yes No Yes No
12. Have you performed any of the following activities for this patient? Random urine screen Date______________ Pill counts Date______________ Pharmacy checks Date______________ Re-evaluated for pain relief and improved physical and psychosocial function 13. Has a specialist consultation been performed or scheduled for this patient? Neurology Board Certified Pain Management Rheumatology
Date______________ No
Yes (please specify) Oncology
Other________________________________________________________________
Please note any other information pertinent to this PA request: ____________________________________________________________ _______________________________________________________________________________________________________________ Prescriber Signature (REQUIRED):________________________________________________________Date: ____________________
(By signature, the physician confirms the above information is accurate and verifiable by patient records.)
Fax This Form to: 866-434-5523
Mail requests to: SXC Health Solutions PA Department, P.O. Box 3214, Lisle IL 60532-8214
Telephone 866-434-5524
SXC Health Solutions, Inc. will provide a response within 24 hours upon receipt.
This facsimile transmission contains legally privileged and confidential information intended for the parties identified below. If you have received this transmission in error, please immediately notify us by telephone and return the original message to P.O. Box 3214; Lisle, IL 60532-8214. Distribution, reproduction or any other use of this transmission by any party other than the intended recipient is strictly prohibited.
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Revised 2/04/12