Form 6014 Ks Oxyc 0407 - Oxycodone Quantity Limit Prior Authorization Physician Fax Form
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1OXYCODONE QUANTITY LIMIT
PRIOR AUTHORIZATION
Clear Data
Physician Fax Form
BCBS Kansas REQUIRES that this form be completed by the prescriber. This form is for prospective, concurrent and retrospective reviews.
The following documentation is REQUIRED for prior authorization. Incomplete forms will be returned for additional information.
To ensure you are submitting this form correctly, you can complete and submit it directly to us online at
For formulary information, please visit the Blue Cross and Blue Shield of Kansas website at
PATIENT AND INSURANCE INFORMATION
Today’s Date:
Patient Name (First):
Last:
M:
DOB (mm/dd/yyyy):
Patient Address:
City, State, Zip:
Patient Telephone:
ID Number:
Group Number:
PHYSICIAN/CLINIC INFORMATION
Prescriber Name:
Physician NPI#:
Specialty:
Contact Name:
Clinic Name:
Clinic Address:
City, State, Zip:
Phone #:
Secure Fax #:
PLEASE ATTACH ANY ADDITIONAL INFORMATION THAT SHOULD BE CONSIDERED WITH THIS REQUEST
Patient’s Diagnosis:
Medication Requested:
Strength:
Dosing Schedule:
Quantity per Month:
1.
Is the patient currently treated with the requested medication? .........................................................................
Yes
No
If yes, when was treatment with the requested medication started? _______________________________
2.
Is this request for dose titration? .......................................................................................................................
Yes
No
3.
Does the patient have a diagnosis of active cancer pain due to an active malignancy? ...................................
Yes
No
4.
Is the patient eligible for hospice care? .............................................................................................................
Yes
No
5.
Is the patient undergoing treatment for chronic non-cancer pain? .....................................................................
Yes
No
If yes, please answer the following questions:
Is there a patient-specific pain management plan on file for the patient? .................................................
Yes
No
For state’s with prescription drug monitoring program (PDMP), has the prescriber reviewed PDMP for this
patient and confirmed that the patient is not diverting the requested medication? ...................................
Yes
No
6.
Please list all reasons for selecting the requested medication over alternatives (e.g. contraindications, allergies or history of
adverse drug reactions to alternatives.) __________________________________________________________________
_________________________________________________________________________________________________
7.
Please list all medications the patient has previously tried and failed for treatment of this diagnosis. (Please specify if the
patient has tried brand-name products, generic products or over-the-counter products.) ____________________________
_________________________________________________________________________________________________
8.
Please list all non-pharmacological therapy the patient has previously tried and failed for treatment of this diagnosis.
(Please specify if the patient has tried brand-name products, generic products or over-the-counter products) ____________
_________________________________________________________________________________________________
9.
Please list any other medications or non-pharmacological therapies the patient will use in combination with the requested
medication for treatment of this diagnosis. ________________________________________________________________
_________________________________________________________________________________________________
Please fax or mail this form to:
CONFIDENTIALITY NOTICE: This communication is intended only for
Prime Therapeutics LLC
the use of the individual entity to which it is addressed, and may contain
Clinical Review Department
information that is privileged or confidential. If the reader of this message
1305 Corporate Center Drive
is not the intended recipient, you are hereby notified that any
Eagan, Minnesota 55121
dissemination, distribution or copying of this communication is strictly
prohibited. If you have received this communication in error, please notify
the sender immediately by telephone at 866.469.5660, and return the
TOLL FREE
original message to Prime Therapeutics via U.S. Mail. Thank you for your
Fax: 877.480.8130
Phone: 866.469.5660
cooperation.
Blue Cross and Blue Shield of Kansas is an independent licensee of the Blue Cross Blue Shield Association. BLUE CROSS
, BLUE SHIELD
and the Cross and Shield Symbols are registered service marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross
and Blue Shield Plans. Prime Therapeutics LLC is an independent limited liability company providing pharmacy benefit management services.
PRIME THERAPEUTICS LLC 04/16
6014 KS OXYC 0407
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