"Long Acting Sustained Release Opioid Prior Authorization (Pa) Request Form - Ct Medical Assistance Program" - Connecticut

Long Acting Sustained Release Opioid Prior Authorization (Pa) Request Form - Ct Medical Assistance Program is a legal document that was released by the Connecticut State Department of Social Services - a government authority operating within Connecticut.

Form Details:

  • Released on April 1, 2017;
  • The latest edition currently provided by the Connecticut State Department of Social Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Social Services.

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Download "Long Acting Sustained Release Opioid Prior Authorization (Pa) Request Form - Ct Medical Assistance Program" - Connecticut

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STATE OF CONNECTICUT DEPARTMENT OF SOCIAL SERVICES
TELEPHONE: 1-866-409-8386 FAX: 1-866-759-4110 OR (860) 269-2035
(This and other PA forms are posted on
www.ctdssmap.com
and can be accessed by clicking on the pharmacy icon)
CT Medical Assistance Program
Long Acting Sustained Release Opioid Prior Authorization (PA) Request Form
To Be Completed By Prescriber
Prescriber Information
Patient Information
Patient Medicaid ID Number:
Prescriber’s NPI:
Prescriber Name:
Patient Name:
Phone #: (
)
Patient DOB:
/
/
Fax #: (
)
Primary ICD Diagnosis Code:
Prescription Information
Drug Requested:
Dose/frequency:
Expected Duration:
□ New therapy
□ Continuation
This form must be completed by the prescribing provider. If the form is missing information, the PA will not be
processed.
Clinical Information
Is the patient 12 years of age or older?
□ Yes
□ No
Does the patient have a diagnosis of cancer?
□ Yes
□ No*
Is the patient under the care of an Oncologist or pain specialist who is experienced in the use of
□ Yes
□ No*
Schedule II opioids to treat cancer pain?
Is the patient free from all of the following contraindications: hypersensitivity to opiates,
□ Yes
□ No*
hypoxia/hypercarbia, severe asthma or chronic obstructive pulmonary disease, or paralytic ileus?
The patient needs an ongoing, continuous course of therapy and not on an as needed basis.
□ Yes
□ No
If you answered 'YES' to all of the questions above, please fax the completed form to the DXC
Technology Pharmacy PA Assistance Center at the number above for processing.
*
If you answered ‘NO’ to any of the questions above, a Letter of Medical Necessity (LMN) must be reviewed by
the Medical Director for consideration. Please provide all relevant information relating to the medical necessity (see
Conn. Gen. Stat. § 17b-259b(a)) of a Long Acting Sustained Release Opioid for this patient. Submit request, via fax,
to 860-424-4822.
I certify that documentation is maintained in my files and the information given is true and accurate for the medication requested, subject to penalty under section 17b-99 of
the Connecticut General Statutes and sections 17-83k-1-13 and 4a-7, inclusive, of the Regulations of Connecticut State Agencies. I certify that the client is under my
I certify that I am a practitioner and hold a current, unrestricted license that allows me to prescribe medication and that I am
clinic’s/practice’s ongoing care.
enrolled in the CT Medical Assistance Program.
Prescriber Signature: ____________________________________________Date:_________________
This form (and attachments) contains protected health information (PHI) for DXC Technology and is covered by the Electronic Communications Privacy Act, 18 U.S.C. §
2510-2521 and the Standards for Privacy of Individually Identifiable Health Information, 45 CFR Parts 160 and 164, which is intended only for the use of prior authorization.
Any unintended recipient is hereby notified that the information is privileged and confidential, and any use, disclosure, or reproduction of this information is prohibited. Any
unintended recipient should contact DXC Technology by telephone at (860) 255-3900 or by e-mail immediately and destroy the original message.
Page 1 of 1
Long Acting Opioid PA Form 04/2017
STATE OF CONNECTICUT DEPARTMENT OF SOCIAL SERVICES
TELEPHONE: 1-866-409-8386 FAX: 1-866-759-4110 OR (860) 269-2035
(This and other PA forms are posted on
www.ctdssmap.com
and can be accessed by clicking on the pharmacy icon)
CT Medical Assistance Program
Long Acting Sustained Release Opioid Prior Authorization (PA) Request Form
To Be Completed By Prescriber
Prescriber Information
Patient Information
Patient Medicaid ID Number:
Prescriber’s NPI:
Prescriber Name:
Patient Name:
Phone #: (
)
Patient DOB:
/
/
Fax #: (
)
Primary ICD Diagnosis Code:
Prescription Information
Drug Requested:
Dose/frequency:
Expected Duration:
□ New therapy
□ Continuation
This form must be completed by the prescribing provider. If the form is missing information, the PA will not be
processed.
Clinical Information
Is the patient 12 years of age or older?
□ Yes
□ No
Does the patient have a diagnosis of cancer?
□ Yes
□ No*
Is the patient under the care of an Oncologist or pain specialist who is experienced in the use of
□ Yes
□ No*
Schedule II opioids to treat cancer pain?
Is the patient free from all of the following contraindications: hypersensitivity to opiates,
□ Yes
□ No*
hypoxia/hypercarbia, severe asthma or chronic obstructive pulmonary disease, or paralytic ileus?
The patient needs an ongoing, continuous course of therapy and not on an as needed basis.
□ Yes
□ No
If you answered 'YES' to all of the questions above, please fax the completed form to the DXC
Technology Pharmacy PA Assistance Center at the number above for processing.
*
If you answered ‘NO’ to any of the questions above, a Letter of Medical Necessity (LMN) must be reviewed by
the Medical Director for consideration. Please provide all relevant information relating to the medical necessity (see
Conn. Gen. Stat. § 17b-259b(a)) of a Long Acting Sustained Release Opioid for this patient. Submit request, via fax,
to 860-424-4822.
I certify that documentation is maintained in my files and the information given is true and accurate for the medication requested, subject to penalty under section 17b-99 of
the Connecticut General Statutes and sections 17-83k-1-13 and 4a-7, inclusive, of the Regulations of Connecticut State Agencies. I certify that the client is under my
I certify that I am a practitioner and hold a current, unrestricted license that allows me to prescribe medication and that I am
clinic’s/practice’s ongoing care.
enrolled in the CT Medical Assistance Program.
Prescriber Signature: ____________________________________________Date:_________________
This form (and attachments) contains protected health information (PHI) for DXC Technology and is covered by the Electronic Communications Privacy Act, 18 U.S.C. §
2510-2521 and the Standards for Privacy of Individually Identifiable Health Information, 45 CFR Parts 160 and 164, which is intended only for the use of prior authorization.
Any unintended recipient is hereby notified that the information is privileged and confidential, and any use, disclosure, or reproduction of this information is prohibited. Any
unintended recipient should contact DXC Technology by telephone at (860) 255-3900 or by e-mail immediately and destroy the original message.
Page 1 of 1
Long Acting Opioid PA Form 04/2017