Opioid Prior Authorization Form Form

Fidelis Care Opioid Prior Authorization Form (8/2023)

This form and Fidelis Care formulary are available at https://www.fideliscare.org/en-us/providers/pharmacyservices.aspx Instructions: THIS FORM IS NOT VALID WITHOUT SIGNATURE. To avoid unnecessary delays, please print neatly and complete in its entirety. Fax this form to 1-844-235-4852. For questions call 1-888-FIDELIS (1-888-343-3547).
CDC Guidelines for Opioid prescribing for Chronic Pain: OPIOIDS ARE NOT RECOMMENDED AS FIRST-LINE TREATMENT FOR CHRONIC PAIN. Please see https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm for additional information.

Prior Authorization is required for:

1. Immediate-Release/Extended-Release Opioids exceeding a cumulative daily dose of 90 Morphine-Milligram Equivalents (MME)
2. Immediate-Release/Extended Release Opioids exceeding the Quantity Limit
3. New starts of Extended-Release Opioids require an initial trial of at least a 7 day supply of an immediate-release opioid analgesic (Commercial lines of business only)

4. New Immediate-Release opioid analgesics exceeding a 7 day supply without prior history of opioid use

   Member Name (last, first) _ Member ID# ___ Date of birth ___/___/____ Sex Male  Female 
   Prescriber Name __ Specialty _ Contact Person_
   Address ___ City, ST, Zip ___ Phone# _ Ext ___ Fax# _

   Medication(s) Requested (strength, route, frequency, duration, and quantity)____ _ _ __ Current Diagnosis / ICD-10 and Other Significant Medical History (attach medical chart notes) _ _ Medical Justification (to avoid delays, SUBMIT CLINICAL CHART NOTES supporting response to each question)

5. Is the requested medication being prescribed for pain associated with cancer, a terminal condition, sickle cell, or is the member in hospice / palliative care? Yes  No 
6. Is the requested medication being used to treat Acute Pain (pain lasting LESS THAN 90 days)? Yes  No 
   (If yes, submit clinical rationale for use of opioid medication lasting longer than a 7 day supply) Is this medication being used to treat Chronic Pain (pain lasting MORE THAN 90 days)? Yes □ No □
7. Which non-opioid therapies has the member tried to treat their pain condition? (submit clinical chart notes documenting trial history; formulary options available at https://www.fideliscare.org/en-us/providers/pharmacyservices.aspx)
8. Does the member require a cumulative dose of opioids exceeding the recommended 90 (MME) per day? Yes  No 
   (If yes, submit clinical chart notes documenting the underlying diagnosis related to pain, clinical rationale for high dose)
9. Has documentation of a positive urine drug screen been provided? Yes  No 
10. Will benzodiazepines be excluded from the member’s treatment plan in accordance with CDC recommendations Yes  No  (By checking no, opioid prescriber acknowledges and approves concurrent use)

11. If member exhibits signs of opioid use disorder, will referral be made to a treatment program? Yes  No 

    I attest that this information is accurate and true, and that the supporting documentation is available for review upon request of said plan, the NYSDOH or CMS. I understand that any person who knowingly makes or causes to be made a false record or statement that is material to a Medicaid MC claim may be subject to civil penalties and treble damages under both federal and NYS False Claims Acts. As indicated in the NYSDOH Medicaid Update (2/201, Volume 3, No. 02), third party phone or fax requests will not be accepted. If a prescriber grants a pharmacy the authority to handle his/her PA requests, the prescriber’s actions would be considered “patient steering,” as this arrangement does not give the patient a choice as to where they go to get their drugs. Per the Medicaid Update, this action may be reported to the Office of Medicaid Inspector General.

    Prescriber’s Signature: ____ Date: ____

    90 Morphine Milligram Equivalents (MME) Morphine 90 mg Hydromorphone 22.5 mg Hydrocodone 90 mg Fentanyl Patch 37.5 MCG Oxycodone
    60 mg Codeine 600 mg Oxymorphone 30 mg Equivalent doses are based on MME conversion factors from CDC Guidelines for Opioid Prescribing in Chronic Pain

    URGENT
    REQUEST

    CHECK
     If the request is for a life threatening condition that is dependent on a priority review from the Fidelis Care Pharmacy Department, you may request an expedited review. Please be considerate of other providers and patients who are also requesting prior authorization.