Currentblue cross blue shield - alabamaPolicy N/A

Opioids Request Form

A prescriber-completed prior authorization form for opioid medications (extended-release and immediate-release) used by Blue Cross Blue Shield - Alabama to collect required clinical, medication history, and documentation to support prior authorization decisions.

Policy Summary

Payerblue cross blue shield - alabama

PolicyOpioids Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must complete the form, include required documentation (medication history, consultative evaluation if chronic non-cancer pain, pain management plan, PDMP confirmation where applicable) and fax or mail to the specified Pharmacy Review address/fax.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes

2Opioid request types covered on form

3Key required documentation items

Policy overview

This is a prescriber-completed prior authorization form used by Blue Cross Blue Shield - Alabama to collect required clinical, medication history, and administrative information to evaluate requests for opioid medications (both extended-release and immediate-release). Only the prescriber may complete and sign the form.

For Opioid Extended-Release (ER) requests the form requires confirmation that the patient’s medication history includes a trial of at least 7 days of an immediate-acting opioid, and captures hospice eligibility and chronic cancer pain status (with medical record documentation required for hospice or active malignancy). If treatment is for chronic non-cancer pain, the prescriber must provide a Formal Consultative Evaluation (diagnosis and complete medical history including prior and current pharmacologic and non-pharmacologic therapy), confirm a patient-specific pain management plan is on file, and confirm PDMP review regarding diversion where applicable.

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Form submission & required documentation

General Submission Requirements

Form must be completed by prescriber with patient, insurance, prescriber and medication information and supporting documentation.

Prescriber completes form (only prescriber may complete this form).

Provide patient identifying information (name, DOB, address, phone).

Provide insurance information (Member ID, Group Number).

Provide prescriber/clinic information (name, NPI, specialty, clinic name, contact, phone, secure fax).

Provide medication requested: medication name, strength, dosing schedule, quantity per month.

List prior medications tried and failed for the diagnosis (dates provided).

List reasons for selecting requested medication over alternatives (contraindications, allergies, adverse reactions, dose trials).

List concurrent medications the patient will take in combination with the requested medication.

Submission Instructions

How to submit the completed form to the plan.

Fax or mail the signed and completed form to Pharmacy Review Post Office Box 529 Auburn, AL 36381.

Toll free fax: 1-866-606-6021.

Prescriber signature and date required on form.

Extended-release (ER) opioid requests — required confirmations

ALL of the following

The patient's medication history includes a trial of at least 7 days of an immediate-acting opioid.Immediate-acting opioid trial for ER requests
Prescriber must confirm a 7-day trial of an immediate-acting opioid prior to ER approval.
Patient status exceptions
- The patient is eligible for hospice care.
  Provide medical record documentation for hospice eligibility.
- The patient has a diagnosis of chronic cancer pain due to an active malignancy.
  Provide medical record documentation for active malignancy.
If treatment is for chronic non-cancer pain then must provide
- Formal Consultative Evaluation including diagnosis and a complete medical history which includes previous and current pharmacological and non-pharmacological therapy.
  A formal consultative evaluation is required for chronic non-cancer pain requests.
- A patient-specific pain management plan is on file for the patient.
  Prescriber must confirm that a pain management plan is documented.
- Prescriber has checked the state's Prescription Drug Monitoring Program (PDMP) and confirmed the patient is not diverting the requested medication.
  Prescriber must document PDMP review.

Documentation Required

Required documentation and provider actions

Provider must supply documentation with the request: Confirm the 7-day immediate-acting opioid trial and include copies of the required records listed below.

Medical record documentation for hospice eligibility or active malignancy (when applicable).
Formal Consultative Evaluation for chronic non-cancer pain (must include diagnosis, complete medical history, prior and current therapies).
Patient-specific pain management plan on file.
PDMP query documentation showing prescriber has confirmed no diversion.
Medical records demonstrating the 7-day trial of an immediate-acting opioid.

Immediate-release (IR) opioid requests — required confirmations

Opioid Immediate-Release (IR) Requests

Required confirmations and documentation for IR opioid prior authorization requests.

Confirm whether patient is opioid naive (defined as 7 days or greater without opioid and not taking an opioid every day in the previous 60 days; patients who received opioids in a hospital are considered opioid naive).7 days or greater without opioid; not taking opioid every day in previous 60 days

Checkbox YES/NO on form

Patient status exceptions

Patient eligible for hospice care.
Provide medical record documentation; Checkbox YES/NO
Patient has diagnosis of chronic cancer pain due to an active malignancy.
Provide medical record documentation; Checkbox YES/NO
Treatment is for chronic non-cancer pain.
If YES, must provide Formal Consultative Evaluation and confirm pain management plan and PDMP check

If treatment is for chronic non-cancer pain then must provide

Formal Consultative Evaluation including diagnosis and a complete medical history which includes previous and current pharmacological and non-pharmacological therapy.
Checkbox YES/NO on form
Prescriber has confirmed that a patient-specific pain management plan is on file for the patient.
Checkbox YES/NO on form
Prescriber has confirmed patient is not diverting the requested medication according to state's PDMP if applicable.
Checkbox YES/NO on form

All of the above confirmations and documentation must be provided for IR request review.

Documentation Required

Opioid-naive definition and form checkbox (IR requests)

Opioid-naive is defined on the form as 7 days or greater without being on an opioid and not taking an opioid every day in the previous 60 days (patients who received opioids in a hospital are considered opioid naive). The prescriber must indicate the opioid-naive checkbox on the form for IR requests.

Opioid-naive definition: 7 days or greater without opioid and not taking an opioid every day in the previous 60 days; hospital opioid exposure counts as naive.
Check the opioid-naive YES/NO box on the IR request section of the form.

Actions required of prescribers

Prior Authorization

Complete and submit prior authorization form

Prescriber must complete and sign the prior authorization form and submit it with required attachments. Required attachments include medication history, a Formal Consultative Evaluation when the request is for chronic non-cancer pain, a patient-specific pain management plan, and confirmation of PDMP review if applicable. Fax or mail the signed and completed form to Pharmacy Review at Post Office Box 529, Auburn, AL 36381 or toll-free fax 1-866-606-6021.

Medication history (list of prior medications tried and failed).
Formal Consultative Evaluation for chronic non-cancer pain (if applicable).
Patient-specific pain management plan (confirmation).
PDMP confirmation/confirmation checkbox (if applicable).
Submission: Pharmacy Review, PO Box 529, Auburn, AL 36381; Toll free fax: 1-866-606-6021.

Documentation Required

Medical record documentation for hospice or active malignancy

If the patient is eligible for hospice care or has chronic cancer pain from an active malignancy, provide supporting medical record documentation with the request (there are YES/NO checkboxes on the form to indicate these conditions).

Attach medical record documentation for hospice eligibility.
Attach medical record documentation for active malignancy/chronic cancer pain.

Documentation Required

Confirm PDMP review

The prescriber must confirm that the patient is not diverting the requested medication according to the state's PDMP when applicable. The form includes a prescriber confirmation checkbox for PDMP review.

Confirm PDMP review and check the corresponding YES/NO box on the form.

Documentation Required

Formal Consultative Evaluation for chronic non-cancer pain

For treatment of chronic non-cancer pain, provide a Formal Consultative Evaluation that includes the diagnosis and a complete medical history covering previous and current pharmacologic and non-pharmacologic therapies. The form includes a checkbox to indicate this evaluation is provided.

Formal Consultative Evaluation including diagnosis.
Complete medical history including previous and current pharmacologic and non-pharmacologic therapy.
Check the Formal Consultative Evaluation YES/NO box on the form.

Documentation Required

Maintain patient-specific pain management plan

Prescriber must confirm that a patient-specific pain management plan is on file for the patient; the form contains a checkbox for this confirmation which must be completed.

Ensure a patient-specific pain management plan is documented and on file.
Check the pain management plan YES/NO box on the form.

Policy Summary

Payerblue cross blue shield - alabama

PolicyOpioids Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Opioids Request Form

Policy overview

Form submission & required documentation

Extended-release (ER) opioid requests — required confirmations

Immediate-release (IR) opioid requests — required confirmations

Actions required of prescribers

Definitions & thresholds

Document revision history