New York State Medicaid Preferred Drug Program
Opioid Agents Prior Authorization Worksheet
To request prior authorization via fax, please complete the Standardized fax form. A faxed request takes up to 24 hours and processing may be delayed if information submitted is illegible or incomplete. PA requests from 3rd party agencies to include faxes or any media are not allowed. Please have the prescribing physician or an an agent employed by the prescribing practitioner contact our department for consideration of this request. If your fax includes the standardized fax form, only the Member Name, ID, DOB, and Clinical Criterianeed to be completed and faxed as an attachment to process your request.
Enrollee Information /enrollee Name:
enrollee medicaid Id number (2 letters, 5 numbers, 1 letter): / enrollee date of birth:
Prescriber Information /
prescriber Name:
Contact person:
10-digit Npi number: / office Phone Number:
( ) - / office Fax number:
( ) -
Drug Information /
Opioid Agent:
Name:
strength:
direction:
quantity:
refills:
Clinical Criteria (Prescription Fill/Refill Limit) /
Diagnosis:
Patients are limited to a total of four opioid prescription fills per rolling 30 days. What is the clinical rationale for exceeding four fills of any opioid prescription per month?:
Please provide current long-acting and short-acting opioid therapy:
Medication / Start Date / Strength / Frequency
Preferred Drug List /
Is a non-preferred opioid agent being prescribed? (Please refer to the PDL at newyork.fhsc.com for a current list of preferred and non-preferred agents)
Yes No
If Yes, please provide clinical rationale for use of a non-preferred agent (Form Cannot be Processed without Required Explanation):
Patient has experienced a treatment failure with a preferred drug. / Yes No
Patient has experienced an adverse drug reaction with a preferred drug. / Yes No
There is a documented history of successful therapeutic control with a nonpreferred drug and transition to a preferred drug is medically contraindicated. / Yes No
Other (Please specify the clinical reason the patient is unable to use a preferred agent in the same drug class. If necessary, fax additional pages):
Step Therapy /
Nucynta ER (Long Acting Opioid) /
Is the patient naïve to long acting opioid therapy?
Yes No
If Yes, has your patient experienced a treatment failure or adverse reaction to Nucynta IR (immediate release)?
Yes No
Nucynta IR (Short Acting Opioid)
Has your patient experienced a treatment failure or adverse reaction to tramadol plus 1 other preferred short-acting opioid?
Yes No
Tramadol ER
Has your patient experienced a treatment failure or adverse reaction to immediate release tramadol?
Yes No
If no, is the prescriber willing to change?
Yes No
ConZip/Ryzolt/Ultram ER
Has your patient experienced a treatment failure or adverse reaction to immediate release tramadol?
Yes No
Has your patient experienced a treatment failure or adverse reaction to the generic, tramadol ER?
Yes No
If no, is the prescriber willing to change?
Yes No
Soma Products
Has your patient experienced a treatment failure or adverse reaction to 1 preferred analgesic plus 2 preferred skeletal muscle relaxants?
Yes No
Therapeutic Duplication /
Two Long Acting Opioids (Applies to LAO, Tramadol ER products, and Methadone) /
What is the clinical rationale for the patient requiring concurrent use of two or more long acting opioids?
Please list long acting opioid(s):
Opioid/Benzodiazepine (Applies to all SAO & LAO, Tramadol ER products, Methadone, Soma compound w/codeine, & Fentanyl Mucosal Agents)
What is the clinical rationale for the patient requiring concurrent use of a benzodiazepine and an opioid?
Please list the Benzo product(s):
Opioid/Buprenorphine (Applies to all SAO & LAO, Tramadol ER products, Methadone, Soma compound w/codeine, & Fentanyl Mucosal Agents)
Is the patient currently taking a Buprenorphine product?
Yes No
Are you willing to prescribe a non-opiate analgesic (i.e. NSAID, etc.)?
Yes No
Is the patient having surgery or had an acute event requiring narcotic pain medication?
Yes No
What is the clinical rationale for the patient requiring concurrent use of an opioid and a buprenorphine product?
Frequency/Quantity/Duration (F/Q/D) /
For all Short Acting and Long Acting Opioids
Does quantity prescribed exceed the recommended dosage? (Please refer to the PDL at newyork.fhsc.com)
Yes No
If Yes, please provide clinical reason:
For Long Acting Opioids, Methadone and Tramadol ER products
For an initial fill for an opioid naïve patient, please provide a clinical rationale for requesting a long acting opioid in an opioid naïve patient.
Does quantity prescribed exceed the per day limit? (Please refer to the PDL at newyork.fhsc.com)
Yes No
If Yes, please provide clinical rationale for exceeding the FDA approved/Compendia supported quantity limit:
For Short Acting Opioids only
Medicaid limits the first fill of an opioid to a 7 day’s supply for opioid naïve patients. What is the clinical rationale for exceeding the 7 day’s supply initial fill duration limit?
For Short Acting Opioids only (for requests that exceed the 90 day duration limit)
Are you currently tapering the patient off their short-acting narcotic and attempting to utilize different treatment options?
Yes No
(Patients with a diagnosis of neuropathic pain) Has the patient attempted to utilize an anti-seizure or antidepressant medication FDA approved for the management of neuropathic pain?
Yes No
If no, is the prescriber willing to change to an anti-seizure or antidepressant medication FDA approved for the management of neuropathic pain?
Yes No
(Patients with a diagnosis of low back pain/musculoskeletal pain and request is for a single entity SAO) Has the patient attempted to utilize acetaminophen or a non-steroidal anti-inflammatory drug?
Yes No
If no, is the prescriber willing to change to acetominophen or a preferred NSAID?
Yes No
Is the patient currently on a long acting opioid?
Yes No
Is the long acting opioid being optimized?
Yes No
Has your patient experienced a treatment failure or adverse reaction to a long acting opioid or is there a contraindication to using a long acting opioid?
Yes No
Has the patient’s risk for opioid misuse or abuse been assessed?
Yes No
For Methadone (for requests that exceed max of #12 units per day , #360 units per 30 days)
Is Methadone being prescribed for the treatment of opioid addiction?
Yes No
If yes, Methadone must be billed through a Methadone Maintenance Treatment Program.
Has the patient been assessed for clinical risks of opioid/substance abuse/addiction?
Yes No
Does the patient have an underlying cardiovascular disorder or history of cardiac arrhythmias?
Yes No
Will the patient periodically be clinically assessed for the need for gradual dosage adjustments?
Yes No
What is the clinical rationale for the patient requiring a dose exceeding 120mg/day?
Yes No
For Soma Compound with Codeine
Does quantity or duration prescribed exceed the recommended dosage? (Please refer to the PDL at newyork.fhsc.com)
Yes No
If yes, does the patient belong to a patient population that is at increased risk for harm with carisoprodol containing products such as patients over the age of 65 years, patients with history of drug/substance abuse or addiction, or patients that have concomitant use of other CNS depressants?
Yes No
What is the clinical rationale for exceeding the quantity/duration limit?
I attest that this is medically necessary for this patient and that all of the information on this form is accurate to the best of my knowledge. I attest that documentation of the above diagnosis and medical necessity is available for review if requested by New York Medicaid.
Prescriber’s signature / dateRevision Date: October 13, 2017 / For billing questions, call 1-800-343-9000.
For clinical concerns or Preferred Drug Program questions, visit www.nyhealth.gov and http://newyork.fhsc.com or call 1-877-309-9493. / Page 2
Revision Date: October 13, 2017 / For billing questions, call 1-800-343-9000.
For clinical concerns or Preferred Drug Program questions, visit www.nyhealth.gov and http://newyork.fhsc.com or call 1-877-309-9493. / Page 2