Fentanyl Transdermal System (Duragesic) - Medical Necessity Request Form Page 2

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Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
**Complete page 2 only for Subsequent/Renewal requests**
1. Is the dose being increased, decreased or remaining the same?
□ Increased
- What additional opioid medication(s) is the member taking that necessitates the dose
increase? Include drug name, strength, directions, day supply, and date of last fill.
(NOTE:
Examples of opioids are OxyContin, Avinza, MS Contin, Kadian, Oramorph, Duragesic/Fentanyl,
Opana, Percocet, Dilaudid, Vicodin, etc.)
_____________________________________________________________________
- What was the previous dose of Fentanyl and when was it last filled?
______________________________________________________________
- Will the previous dose be discontinued? Yes or No
□ Decreased
- What was the previous dose of Fentanyl and when was it last filled?
______________________________________________________________
- Will the previous dose be discontinued? Yes or No
□ Remaining the same
2. Is the member currently or will the member be on any other long-acting opioid pain controller? (i.e.
OxyContin, Avinza, MS Contin, Kadian, Oramorph, Duragesic/Fentanyl, Opana ER, Butrans) Yes or No
a. If yes, which long-acting opioid pain controller(s) will the member be receiving concurrently?
____________________________________________________________________________
b. What is the clinical reason why the member is receiving more than one long-acting opioid pain
controller?
_______________________________________________________________________________
How often will the Duragesic patch be applied? (i.e., every 48 hours, every 72 hours, etc)
3.
□ every 48 hours
□ every 72 hours
□ Other: ________________________
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office
2 of 2
Rev. 03/16
HNJH Fax #: 888-567-0681
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