Download Prior Authorization (PA) Short-Acting Opioids Form

Kaiser Permanente Health Plan of Mid-Atlantic States, Inc.
Short-Acting Opioids Prior Authorization (PA)
Pharmacy Benefits Prior Authorization Help Desk
Instructions:
Opioids can provide short-term benefits for moderate to severe acute pain. Scientific evidence is lacking for the benefits of opioids for treatment
of chronic pain. Based on the CDC Guidelines for Prescribing Opioids for Chronic Pain, OPIOIDS ARE NOT RECOMMENDED AS FIRST-LINE
TREATMENT FOR CHRONIC PAIN. Please see http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm for additional information.
Please complete and fax this form back to Kaiser Permanente within 24 hours at fax: 1-866-331-2104. If you have any questions or concerns
please call 1-866-331-2103. Request will not be considered unless form is completely filled out.
The KPMAS VA Medicaid Formulary can be found at:
https://healthy.kaiserpermanente.org/static/health/pdfs/formulary/mid/mid_medicaid.pdf
New Starts: All short acting Opioids are limited to (2) 14-day supply in 60 days. Quantity limits apply to each drug. If the
quantity prescribed exceeds the 14-day supply limit and the drug’s quantity limit, Prior Authorization is required.
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1-Patient Information
Patient Name:_______________________ Kaiser Medical ID#: __________________________________________________________
Date of Birth: _______________
Gender: □ Male □ Female
Phone #: __________________________________________
2-Provider Information
Provider Name:___________________________Provider NPI: _______________________
Provider Address:_____________________________________________________________________________________
Provider Phone #: _________________________Provider Fax #: ________________________________________
Provider’s Specialty:
□ Oncologist
□ Hematology □ Chronic Pain Specialist
□ Palliative Care □ Other: ___________________
3-Alternative Therapy to Schedule II Opioid
Consider alternative therapy to Schedule II opioid drugs due to their high potential for abuse and misuse. Complete list of KPMAS VA Medicaid
formulary can be found at: https://healthy.kaiserpermanente.org/static/health/pdfs/formulary/mid/mid_medicaid.pdf
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NSAIDS topical and oral
Gabapentin CAPS
Lidocaine Patch 5%
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Preferred Alternative Products:
SNRI
Baclofen
Non-Preferred Alternative Products:
Buprenorphine Transdermal Patch 5
mcg/Hour*
Updated September 2016
Tricyclic Antidepressants
Capsaicin topical cream 0.025%
Reserved to Pain Management Prescribers
4- Therapy Prescribed
Drug Name/Form: _____________________________Strength:______________________ Qty Requested:______________
Directions:_________________________________ Length of Therapy:______________________
Is the requested opioid’s daily morphine milligram equivalent dose >/=120 MED? □ Yes □ No. If yes, please submit clinical
rationale:_________________________________________________________________________________________________________
________________________________________________________________________________________________________________
** Daily dose lim its apply. The list can be found at: Daily Quantity limits LAN & SAN
5-Treatment Information
1.
2.
Is this medication used for acute or post-op pain?
□ Yes □ No
If Yes, limit the total day supply to <14 days, complete questions 4-11, sign and fax the form. Daily Quantity limits LAN & SAN. If no,
continue to question 2.
Is this medication being used for one of the following conditions?
End of life
□ Yes □ No
Pallative Care
□ Yes □ No
Sickle Cell
□ Yes □ No
Hospice Care
□ Yes □ No
Active Cancer Diagnosis
□ Yes □ No
If yes, complete questions 5-11, sign and fax the form. If no, continue to question 3.
3.
Is this medication used for chronic pain?
If yes, please complete questions 4-14, sign and fax the form.
□ Yes □ No
4.
Has the patient tried any of the following non-opioid therapies which do not require a prior authorization? (check all that apply)
□ Baclofen
□ NSAID (oral)
□ Diclofenac gel
□ Gabapentin
□ Duloxetine
□ Carbamazepine
□ Capsaicin Gel
□ Tricyclic Antidepressants
5. If requesting a non-preferred product, has the patient failed an adequate trial of preferred product?
□ Yes □ No
If yes, list below:
Drug 1
Strength
Length of Trial
Reason for discontinuation of the drug
Drug 2
Strength
Length of Trial
Reason for discontinuation of the drug
6. Medical Necessity: Provide clinical evidence that the preferred agent(s) will not provide adequate benefit:
__________________________________________________________________________________________________
FDA Black Box W arning: Health care professionals should limit prescribing opioid pain medicines with benzodiazepines or other CNS
depressants only to patients for whom alternative treatment options are inadequate. If these medicines are prescribed together, limit the
dosages and duration of each drug to the minimum possible while achieving the desired clinical effect. Warn patients and caregivers about
the risks of slowed or difficult breathing and/or sedation, and the associated signs and symptoms. Avoid prescribing prescription opioid
cough medicines for patients taking benzodiazepines or other CNS depressants, including alcohol.
http://www.fda.gov/Drugs/DrugSafety/ucm518473.htm
7. Have you counseled your patient of the risks associated with combined use of benzodiazepines and opioids?
Updated September 2016
□ Yes □ No
6-Prescription Monitoring Program (PMP)
8. Attestation: Prescriber has checked the PMP on the date of this request to determine whether the patient is receiving opioid dosages or
dangerous combinations (such as opioids and benzodiazepines) that put him or her at high risk for fatal overdose. PMP website:
https://www.pmp.dhp.virginia.gov/VAPMPWebCenter/login.aspx
□ Yes □ No
9. Document the fill date of the patient’s last opioid Rx: __________________________
10.Document the Fill date for the patient’s last benzo Rx (if applicable): ________________________□ N/A
11. Document the patient’s total drug MEDD (MME) from the PMP site ___________ MEDD
For MEDD:
□ 51 -90 MEDD (Prescriber should consider offering a prescription for naloxone and overdose prevention education
□ > 90 MEDD ( Prescriber should consider offering the patient a prescription for naloxone and overdose
prevention education; plus consider consultation with a pain specialist
7- Treatment Plan
12. Prescriber attests that a treatment plan with goals that addresses benefits and harm has been established with the patient and the
following bullets are included and there is a SIGNED AGREEMENT with the patient. This will be reviewed with the patient within 1 to 4
weeks of starting opioid therapy for chronic pain, with dose escalation and is reviewed every 3 months or more frequently.
Sample Physician/Patient Agreement: www.drugabuse.gov/sites/default/files/files/samplepatientagreementforms.pdf
a.
Established expected outcome and improvement in both pain relief and function or just pain relief as well as
limitations (i.e., Function may improve yet pain persist OR pain may never be totally eliminated)
b.
Established goals for monitoring progress toward patient-centered functional goals; e.g., walking the dog or walking
around the block, returning to part-time work, attending family sports or recreational activities, etc.
c.
Goals for pain and function, how opioid therapy will be evaluated for effectiveness and the potential need to
discontinue if not effective
d.
Emphasize serious adverse effects of opioids (including fatal respiratory depression and opioid use disorder, OR alter
the ability to safely operate a vehicle)
e. Emphasize common side effects of opioids (constipation, dry mouth, nausea, vomiting, drowsiness, confusion,
tolerance, physical dependence, withdrawal)
13. If patient exhibits any signs of opioids use disorder, please consider referring the patient to a substance use disorder treatment
program.
14. A presumptive urine drug screen (UDS) MUST be done if treatment lasts longer than 90 days.
Yes □ No
□
a) The UDS must check for the prescribed drug prescribed plus a minimum of 10 substances including heroin, prescription opioids,
cocaine, marijuana, benzodiazepines, amphetamines, and metabolites.
□ Yes □ No
b) The UDS must be completed within 7 days of the prior reqal.
□ Yes □ No
c) A copy of the UDS is attached. If no, please explain.
□ Yes □ No
If No to any of the above, please explain_____________________________________________________________________________
8- Provider Sign off
I certify that the information provided is accurate. Supporting documentation is available for State audits.
Physician Signature__________________________________
Date:
Please Note: This document contains confidential information, including protected health information, intended for a specific individual and purpose. The information is private and
legally protected by law, including HIPAA. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or taking of any action in reliance
on the contents of this telecopied information is strictly prohibited. Please notify sender if document was not intended for receipt by your facility
Updated September 2016