COMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Service Authorization Form
Short-Acting Narcotics
If the following information is not complete, correct, or legible, the SA process can be delayed. Use one form per member please.
All short acting opioids are limited to a 10-day supply. if the quantity exceeds a 10-day supply, then a service authorization (SA) is required. Depending
on supporting information, a SA for up to three months may be approved.
PATIENT INFORMATION
LAST NAME:
FIRST NAME:
MEDICAID ID NUMBER:
DATE OF BIRTH:
–
GENDER:
Male
–
Female
PRESCRIBER INFORMATION
LAST NAME:
FIRST NAME:
SPECIALTY:
NPI NUMBER:
PHONE NUMBER:
FAX NUMBER:
–
–
–
–
DRUG INFORMATION
DRUG NAME/FORM
STRENGTH
TOTAL DAILY DOSE
DIRECTIONS
LENGTH OF THERAPY
QUANTITY REQUESTED
** Please verify that the daily dose limit is
not exceeded. The list can be found at Daily Dose Limits LAN and SAN.
TREATMENT INFORMATION
Yes
1.
Is this medication being used for acute pain?
2.
Diagnoses that the Short Acting Narcotic is prescribed for longer than a 10-day supply (please check all that apply):
Cancer pain
Hospice patient
Palliative care
End-of-Life Care
Sickle cell disease
Chronic back pain
Arthritis
Fibromyalgia
Diabetic neuropathy
Postherpetic Neuralgia
Breakthrough Pain
Post Surgical Pain
Other:
INITIAL DATE OF DIAGNOSIS:
3.
No
DATE NARCOTIC INITIATED FOR DIAGNOSIS:
Explain in detail why the short-acting narcotic quantity or dose exceeds a 10-day supply.
PRESCRIPTION MONITORING PROGRAM (PMP)
4.
The Prescriber commits to monitoring the PMP with all new prescriptions and discusses with the
patient findings and risks of using other central nervous system depressants, such as benzodiazepines,
alcohol, other sedatives, illicit drugs such as heroin, or other opioids.
Yes
No
PMP website: https://www.pmp.dhp.virginia.gov/VAPMPWebCenter/login.aspx
5.
Document the date the PMP was accessed:
6.
Document the patient’s total drug Morphine Milligram Equivalents from the PMP site
(MME/day).
/
For MME:
From 51 to 90 MME/day (Prescriber must offer Rx for naloxone and overdose prevention education)
>90 MME/day (Must give patient a RX for naloxone and provide overdose prevention education; plus consider consultation
with a pain specialist)
Additional information on MMEs can be found on pages 4 and 5.
Continued on next page Signature MUST be submitted on page 3.
DMAS – P227
06/01
© 2016, Magellan Health, Inc. All Rights Reserved.
Revision Date: 06/01/2016
http://www.virginiamedicaidpharmacyservices.com
COMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Service Authorization Form
Short-Acting Narcotics
LAST NAME:
FIRST NAME:
7.
Has the patient been on another short-acting narcotic within the last 30 days?
Yes
No
8.
Has the patient been on another short-acting narcotic within the last 30 days by another provider?
Yes
No
If yes, has the medication been discontinued?
Yes
No
CLINICAL CRITERIA DOCUMENTATION
9.
Has the patient tried any of the following non-pharmacological alternatives to Opioids? (please check all that apply):
Physical Therapy
Weight Loss
Arthrocentesis
Psychological Therapies such as cognitive behavioral therapy (CBT)
Aerobic Exercises
Aquatic Exercises
Resistance Exercises
Other:
10. Has the patient been prescribed OR tried any of the following non-opioid pharmacologic therapies? (please check all that apply):
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Muscle Relaxants
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Other:
Anti-convulsants
11. 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 CONTRACT
with the patient.
•
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)
•
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.
•
Goals for pain and function, how opioid therapy will be evaluated for effectiveness and the potential
need to discontinue if not effective
•
Emphasize serious adverse effects of opioids (including fatal respiratory depression and opioid use
disorder, OR alter the ability to safely operate a vehicle)
•
Emphasize common side effects of opioids (constipation, dry mouth, nausea, vomiting, drowsiness,
confusion, tolerance, physical dependence, withdrawal)
Yes
No
12. A presumptive urine drug screen (UDS) MUST be done if treatment last longer than 60 days. 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. A copy of
the most recent UDS is attached.
Yes
No
13. Does this patient exhibit signs of opioid use disorder? (please check all that apply):
History of addiction to the requested drug
Frequent requests for early refills
Frequent requests for odd quantities
Frequent reports of lost or stolen drug
Requests for short term or PRN use of short-acting narcotics
Receiving opioids from more than one prescriber
Please explain any of the above checkboxes:
14. If requesting a non-preferred product, has the patient failed an adequate trial of a preferred product?
If yes, list below:
Yes
No
Drug 1
Strength
Length of Trial
Reason for discontinuation of the drug
Drug 2
Strength
Length of Trial
Reason for discontinuation of the drug
DMAS – P227
© 2016, Magellan Health, Inc. All Rights Reserved.
Revision Date: 06/01/2016
http://www.virginiamedicaidpharmacyservices.com
Page 2 of 5
COMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Service Authorization Form
Short-Acting Narcotics
LAST NAME:
FIRST NAME:
Medical necessity: Provide clinical evidence below that the preferred agent(s) will not provide adequate benefit:
Other Websites for Additional Information
Physician/Patient Contract: https://www.drugabuse.gov/sites/default/files/files/SamplePatientAgreementForms.pdf
CDC Guidelines: http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
Prescriber Signature (Required)
Date
(By signature, the Physician confirms the above information is accurate and verifiable by patient records.)
SERVICE AUTHORIZATION CRITERIA IS SUBJECT TO CHANGE AND THUS DRUG COVERAGE
The completed form may be FAXED TO 800-932-6651, phoned to 1-800-932-6648.
Or mailed to: Magellan Medicaid Administration / 11013 W. Broad St / Glen Allen, VA 23060 / ATTN: MAP
DMAS – P227
© 2016, Magellan Health, Inc. All Rights Reserved.
Revision Date: 06/01/2016
http://www.virginiamedicaidpharmacyservices.com
Page 3 of 5
CALCULATING TOTAL DAILY DOSE
OF OPIOIDS FOR SAFER DOSAGE
Higher Dosage, Higher Risk.
Higher dosages of opioids are associated with higher risk of overdose and death—even relatively
low dosages (20-50 morphine milligram equivalents (MME) per day) increase risk. Higher dosages
haven’t been shown to reduce pain over the long term. One randomized trial found no difference
in pain or function between a more liberal opioid dose escalation strategy (with average final
dosage 52 MME) and maintenance of current dosage (average final dosage 40 MME).
WHY IS IT IMPORTANT TO CALCULATE
THE TOTAL DAILY DOSAGE OF OPIOIDS?
Dosages at or above 50 MME/day
increase risks for overdose by at least
2x
Patients prescribed higher opioid dosages are at higher
risk of overdose death.
In a national sample of Veterans Health Administration (VHA)
patients with chronic pain receiving opioids from 2004–2009,
patients who died of opioid overdose were prescribed an average
of 98 MME/day, while other patients were prescribed an average
of 48 MME/day.
Calculating the total daily dose of opioids helps identify
patients who may benefit from closer monitoring, reduction or
tapering of opioids, prescribing of naloxone, or other measures
to reduce risk of overdose.
the risk at
<20
MME/day.
HOW MUCH IS 50 OR 90 MME/DAY FOR COMMONLY PRESCRIBED OPIOIDS?
50 MME/day:
90 MME/day:
•
50 mg of hydrocodone (10 tablets of hydrocodone/
acetaminophen 5/300)
•
90 mg of hydrocodone (9 tablets of hydrocodone/
acetaminophen 10/325)
•
33 mg of oxycodone (~2 tablets of oxycodone
sustained-release 15 mg)
•
60 mg of oxycodone 12 tablets of hydrocodone/
acetaminophen 7.5/300)
•
12 mg of methadone ( <3 tablets of methadone 5 mg)
•
~20 mg of methadone (4 tablets of methadone 5 mg)
L E A R N M O R E | www.cdc.gov/drugoverdose/prescribing/guideline.html
HOW SHOULD THE TOTAL DAILY DOSE OF OPIOIDS BE CALCULATED?
1
2
DETERMINE the total daily amount
of each opioid the patient takes.
CONVERT each to MMEs—multiply the dose for
each opioid by the conversion factor. (see table)
3
ADD them together.
Calculating morphine milligram equivalents (MME)
OPIOID (doses in mg/day except where noted)
CONVERSION FACTOR
Codeine
0.15
Fentanyl transdermal (in mcg/hr)
2.4
Hydrocodone
1
Hydromorphone
4
Methadone
1-20 mg/day
4
21-40 mg/day
8
41-60 mg/day
10
≥ 61-80 mg/day
12
Morphine
Oxycodone
Oxymorphone
1
1.5
3
These dose conversions are estimated and cannot account for
all individual differences in genetics and pharmacokinetics.
CAUTION:
USE EXTRA CAUTION:
•
• Methadone: the conversion factor increases at
higher doses
Do not use the calculated dose in MMEs to determine
dosage for converting one opioid to another—the new
opioid should be lower to avoid unintentional overdose
caused by incomplete cross-tolerance and individual
differences in opioid pharmacokinetics. Consult the
medication label.
• Fentanyl: dosed in mcg/hr instead of mg/day, and
absorption is affected by heat and other factors
HOW SHOULD PROVIDERS USE THE TOTAL
DAILY OPIOID DOSE IN CLINICAL PRACTICE?
•
Use caution when prescribing opioids at any dosage and prescribe the lowest effective dose.
•
Use extra precautions when increasing to ≥50 MME per day such as:
- Monitor and assess pain and function more frequently.
- Discuss reducing dose or tapering and discontinuing opioids if benefits do not outweigh harms. - Consider offering naloxone.
•
Avoid or carefully justify increasing dosage to ≥90 MME/day.
L E A R N M O R E | www.cdc.gov/drugoverdose/prescribing/guideline.html