Medication Prior Authorization Form - Opioids - Complete and fax to 1-866-240-8123

Sep 17, 2026

Medication prior authorization form for opioids collecting member and provider identification details, including subscriber and physician information, with fields for drug name, strength, requested quantity, directions, and diagnosis/ICD-10 codes. Clinical sections request answers to criteria supporting opioid use, therapy evaluation, non-opioid trial outcomes, monitoring for interactions, and current opioid consistency. Additional questions address cancer-related pain, hospice enrollment, and terminal or remission status, followed by medication history, certification, and submission instructions.

LanguageEnglish

CategoryForms

FormatPDF

Pages3

Reading Time1 min

AccessFree to download

Member Information

Provider Information

Medication Information

Clinical Information

Medication History

Instructions for Completing This Form

Medication Prior Authorization Form Fax to 1-866-240-8123 Opioids Member Information: | Subscriber’s ID Number | | Subscriber’s Group Number | | --- | --- | --- | | Member’s Name | Phone | Date of Birth | | Address City State Zip Code | | | Provider Information: | Physician’s Name | | NPI | Phone | Fax | | --- | --- | --- | --- | --- | | Address City State Zip Code | | | | | | Suite / Building | Physician’s Signature | | | Date | Medication Information: | Drug Name | Drug strength | Requested Quantity | Requested Day Supply ☐ 30 days
☐ 90 days
☐ Other: | | --- | --- | --- | --- | | Directions | | | | | Diagnosis and/or ICD-10 code(s) | | | | Clinical Information: | 1. Please check ALL that apply:
􀂆 The member has chronic pain
􀂆 The member has pain associated with end-of-life care or palliative care
􀂆 The member has pain associated with sickle cell anemia
􀂆 The member resides in a long-term care facility
􀂆 The member has a documented acute pain condition (e.g. , acute traumatic injury) in which treatment with other agents would cause insufficient pain control
􀂆 The member requires treatment for pain related to a terminal illness | | --- | | 2. Please check ALL that apply:
􀂆 The member has pain severe enough to require daily, around-the-clock, long-term opioid treatment
􀂆 The member is NOT opioid naïve
􀂆 At least one of the following therapies have been evaluated:
• Exercise therapy , Physical therapy , Weight loss , Cognitive behavioral therapy
􀂆 Non-opioid therapies have provided an inadequate response or are inappropriate
􀂆 Use of an NSAID (nonsteroidal anti-inflammatory drug) would be inappropriate
􀂆 The member’s history of controlled substance prescriptions has been checked using the state prescription drug monitoring program (PDMP)
􀂆 The member or parent/guardian has been educated on the potential adverse effects of opioid analgesics, includingthe risk of misuse, abuse, and addiction | | 3. Based on the member’s clinical circumstances, is the prescribed amount of opioid warranted in order to adequately manage the member’s pain? | Yes | No | | --- | --- | --- | | 4. Is there an ongoing monitoring plan to identify and address drug-drug interactions between the requested opioid and any opioid potentiators (e.g. , Gabapentin, Horizant, Gralise, Lyrica/Pregabalin, benzodiazepines, sedative-hypnotics, etc. )? | Yes | No | | 5. Is the member currently utilizing opioid therapy on a consistent basis for chronic pain (defined as prescribed use for 90 out of the past 110 days)? | Yes | No | | | | | | 6. Does the member have pain associated with active cancer treatment or cancer not in remission? | Yes | No | | If YES: | | | | 6a. Please provide cancer diagnosis: | | | | | | | | 7. Is the member a cancer survivor being treated for chronic pain? | Yes | No | | If YES: | | | | 7a. Has the member completed cancer treatment? | Yes | No | | 7b. Is the member in clinical remission? | Yes | No | | 7c. Is the member under cancer surveillance only? | Yes | No | | | | | | 8. Is the member currently enrolled in hospice? | Yes | No | | If YES: | | | | 8a. Is this medication being used to treat the member’s
terminal/hospice diagnosis? | Yes | No | | 8b. Is this medication being used to treat a condition related to the
member’s terminal/hospice diagnosis (e.g. , pain, nausea,
constipation, anxiety, etc. )? | Yes | No | Medication History: Please provide any other medications that the member has tried and failed: | | | --- | | | The submitting provider certifies that the information provided is true, accurate, and complete and the requested services are medically indicated and necessary to the health of the member. Note: Payment is subject to member eligibility. Authorization does not guarantee payment. INSTRUCTIONS FOR COMPLETING THIS FORM 1. Submit a separate form for each medication. 2. Please print, type or write legi

FAQs

What information must be provided on the Medication Information section?

The form collects drug name, drug strength, requested quantity, requested day supply option, directions, and diagnosis/ICD-10 code(s).

What clinical criteria are checked to support opioid authorization?

The form asks the provider to confirm applicable pain conditions, opioid necessity factors (including evaluation of other therapies and inadequate non-opioid response), history of opioid use, monitoring for drug-drug interactions, and whether opioid use is consistent for chronic pain.

Where and how should the completed form be submitted?

Fax the completed form and clinical documentation to 1-866-240-8123 or mail it to Clinical Services, 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222. A separate form is required for each medication.

Sep 17, 2026

Upload by Arica Lee