Long Acting Sustained Release Opioid Prior Authorization (Pa) Request Form

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Connecticut Department of Social Services
Medical Assistance Program
Provider Bulletin 2016-79
November 2016
TO
Pharmacy Providers, Physicians, Nurse Practitioners, Physician Assistants, Clinics,
:
Long Term Care Providers, and Hospitals
RE
New Prior Authorization Request Form for Long Acting Sustained Release Opioid
:
Medications
Effective
December
1,
2016,
Prior
3. The patient must be under the care of an
Authorization (PA) will be required for long
Oncologist
or
Pain
Specialist
acting sustained release opioid medications for
experienced in the use of Schedule II
HUSKY A, HUSKY B, HUSKY C, HUSKY D,
opioids to treat cancer pain;
FAMPL and TB clients.
4. The patient does not have any of the
following contraindications:
Prescribing providers who are actively enrolled
• hypersensitivity to opiates,
in the Connecticut Medical Assistance Program
• hypoxia/hypercarbia,
(CMAP) with the following taxonomies will be
• severe asthma or chronic obstructive
excluded from the PA requirement:
pulmonary disease, or
• paralytic ileus.
• 207RH0000X – Physician Hematology
5. The
patient
needs
an
ongoing,
continuous course of therapy and not on
• 207RH0003X – Allopathic & Osteopathic
an as needed basis.
Physicians/Internal Medicine, Hematology
& Oncology
In instances where the individual does not meet
all five (5) criteria, the prescriber may write a
• 207RX0202X – Allopathic & Osteopathic
letter of medical necessity to the Department's
Physicians/Internal
Medicine,
Medical
Medical Director for consideration. Letters of
Oncology
medical necessity should be faxed alongside the
Long Acting Sustained Release Opioid PA
• 2080P0207X – Physician Pediatrics –
Form to (860) 424-4822.
Pediatric Hematology/Oncology
As a reminder, effective 07/1/2016, section 7 of
Please note: Patients currently receiving long
Public Act 16-43 prohibits a prescribing
acting opioid medications will be exempt from
provider from issuing a prescription for more
the PA requirement for a period of six (6)
than a seven day supply with limited
months. This 6 month grace period is to allow
exceptions.
All practitioners who prescribe
time for the prescriber to re-evaluate clients
greater than a seventy-two hour supply of any
currently receiving long acting sustained
controlled substance (Schedule II-V) are
release opioid medications and the need for
required to review the patient’s records in the
using these medications going forward.
Connecticut
Prescription
Monitoring
and
Prior Authorization (PA) Requirements
Reporting
System
(CPMRS)
at
https://connecticut.pmpaware.net.
The full
In order to receive PA for long acting opioid
requirements are discussed in Provider Bulletin
medications, the following criteria must be met:
PB 16-36, released on 06/20/2016.
1. The patient must be age 12 or older;
The new Long Acting Sustained Release Opioid
2. The patient must have a diagnosis of
PA Form is attached below and will be available
cancer;
on the
Web site. From the
Questions? Need assistance? Call the Provider Assistance Center Mon. – Fri. 8:00 a.m. – 5:00 p.m.
Toll free 1-800-842-8440 or write to Hewlett Packard Enterprise, PO Box 2991, Hartford, CT 06104
Program information is available at

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