LAC 46:XLV.8003. Louisiana Uniform Prescription Drug Prior Authorization Form

LOUISIANA UNIFORM PRESCRIPTION DRUG PRIOR AUTHORIZATION FORM SECTION I - SUBMISSION Submitted to: | Phone: | Fax: | Date: SECTION II - PRESCRIBER INFORMATION Last Name, First Name MI: | NPI# or Plan Provider #: | Specialty: Address: | City: | State: | ZIP Code: Phone: | Fax: | Office Contact Name: | Contact Phone: SECTION III - PATIENT INFORMATION Last Name, First Name MI: | DOB: | Phone: | Male Female Other Unknown Address: | City: | State: | ZIP Code: Plan Name (if different from Section I): | Member or Medicaid ID #: | Plan Provider ID: Patient is currently a hospital inpatient getting ready for discharge? ____ Yes ____ No Date of Discharge:________________ Patient is being discharged from a psychiatric facility? ____ Yes ____ No Date of Discharge:________________ Patient is being discharged from a residential substance use facility? ____ Yes ____ No Date of Discharge:________________ Patient is a long-term care resident? ____ Yes ____ No If yes, name and phone number:______________________________ EPSDT Support Coordinator contact information, if applicable: SECTION IV - PRESCRIPTION DRUG INFORMATION Requested Drug Name: Strength: | Dosage Form: | Route of Admin: | Quantity: | Days’ Supply: | Dosage Interval/Directions for Use: | Expected Therapy Duration/Start Date: To the best of your knowledge this medication is: _____New therapy/Initial request _____Continuation of therapy/Reauthorization request For Provider Administered Drugs only: HCPCS/CPT-4 Code: NDC#:_________________Dose Per Administration:______________________ Other Codes:________________________________________________ Will patient receive the drug in the physician’s office? ____Yes ____No – If no, list name and NPI of servicing provider/facility: ______________________________________ SECTION V - PATIENT CLINICAL INFORMATION Primary diagnosis relevant to this request: | ICD-10 Diagnosis Code: | Date Diagnosed: Secondary diagnosis relevant to this request: | ICD-10 Diagnosis Code: | Date Diagnosed: For pain-related diagnoses, pain is: _______Acute ______Chronic For postoperative pain-related diagnoses: Date of Surgery_____________________ Pertinent laboratory values and dates (attach or list below): Date | Name of Test | Value SECTION VI - THIS SECTION FOR OPIOID MEDICATIONS ONLY Does the quantity requested exceed the max quantity limit allowed? ___Yes ___No (If yes, provide justification below.) Cumulative daily MME___________________ Does cumulative daily MME exceed the daily max MME allowed? ___Yes ___No (If yes, provide justification below.) SHORT AND LONG-ACTING OPIOIDS | YES (True) | NO (False) | THE PRESCRIBER ATTESTS TO THE FOLLOWING: SHORT AND LONG-ACTING OPIOIDS | A complete assessment for pain and function was performed for this patient. SHORT AND LONG-ACTING OPIOIDS | The patient has been screened for substance abuse / opioid dependence. (Not required for recipients in long-term care facility.) SHORT AND LONG-ACTING OPIOIDS | The PMP will be accessed each time a controlled prescription is written for this patient. SHORT AND LONG-ACTING OPIOIDS | A treatment plan which includes current and previous goals of therapy for both pain and function has been developed for this patient. SHORT AND LONG-ACTING OPIOIDS | Criteria for failure of the opioid trial and for stopping or continuing the opioid has been established and explained to the patient. SHORT AND LONG-ACTING OPIOIDS | Benefits and potential harms of opioid use have been discussed with this patient. SHORT AND LONG-ACTING OPIOIDS | An Opioid Treatment Agreement signed by both the patient and prescriber is on file. (Not required for recipients in long-term care facility.) LONG-ACTING OPIOIDS | The patient requires continuous around the clock analgesic therapy for which alternative treatment options have been inadequate or have not been tolerated. LONG-ACTING OPIOIDS | Patient previously utilized at least two weeks of short-acting opioids for this condition. Please enter drug(s), dose, duration and date of trial in pharmacologic/non-pharmacologic treatment section below. LONG-ACTING OPIOIDS | Medication has not been prescribed to treat acute pain, mild pain, or pain that is not expected to persist for an extended period of time. LONG-ACTING OPIOIDS | Medication has not been prescribed for use as an as-needed (PRN) analgesic. LONG-ACTING OPIOIDS | Prescribing information for requested product has been thoroughly reviewed by prescriber. IF NO FOR ANY OF THE ABOVE (A-L), PLEASE EXPLAIN: SECTION VII - PHARMACOLOGIC & NON-PHARMACOLOGIC TREATMENT(S) USED FOR THIS DIAGNOSIS (BOTH PREVIOUS & CURRENT): Drug name | Strength | Frequency | Dates Started and Stopped or Approximate Duration | Describe Response, Reason for Failure, or Allergy Drug Allergies: | Height (if applicable): | Weight (if applicable): Is there clinical evidence or patient history that suggests the use of the plan’s pre-requisite medication(s), e.g. step medications, will be ineffective or cause an adverse reaction to the patient? ____Yes ____No (If yes, please explain in Section VIII below.) SECTION VIII - JUSTIFICATION (SEE INSTRUCTIONS) By signing this request, the prescriber attests that the information provided herein is true and accurate to the best of his/her knowledge. Also, by signing and submitting this request form, the prescriber attests to statements in the ‘Attestation’ section of the criteria specific to this request, if applicable. Signature of Prescriber:___________________________________________ Date:____________________