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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.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/medication-prior-authorization-form-opioids-complete-and-fax-to-1-866-240-8123/288683/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/medication-prior-authorization-form-opioids-complete-and-fax-to-1-866-240-8123/288683.png","ImageObject",442,249,{"name":88,"@type":89},"Arica Lee","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":73},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information must be provided on the Medication Information section?","Question",{"text":108,"@type":109},"The form collects drug name, drug strength, requested quantity, requested day supply option, directions, and diagnosis/ICD-10 code(s).","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What clinical criteria are checked to support opioid authorization?",{"text":113,"@type":109},"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.",{"name":115,"@type":106,"acceptedAnswer":116},"Where and how should the completed form be submitted?",{"text":117,"@type":109},"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.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288683,1790148915,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":73,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},8796096645457,"https://ap-avatar.wpscdn.com/avatar/800003749518d68ffe3?x-image-process=image/resize,m_fixed,w_180,h_180&k=1779345340919836971","Medication Prior Authorization Form Fax to 1-866-240-8123  \nOpioids  \nMember Information:  \n\n| Subscriber’s ID Number |  | Subscriber’s Group Number |\n| --- | --- | --- |\n| Member’s Name | Phone | Date of Birth |\n| Address City State Zip Code |  |  |\n\nProvider Information:  \n\n| Physician’s Name |  | NPI | Phone | Fax |\n| --- | --- | --- | --- | --- |\n| Address City State Zip Code |  |  |  |  |\n| Suite / Building | Physician’s Signature |  |  | Date |\n\nMedication Information:  \n\n| Drug Name | Drug strength | Requested Quantity | Requested Day Supply ☐ 30 days\u003Cbr>☐ 90 days\u003Cbr>☐ Other:   |\n| --- | --- | --- | --- |\n| Directions |  |  |  |\n| Diagnosis and/or ICD-10 code(s) |  |  |  |\n\nClinical Information:  \n\n| 1. Please check ALL that apply:\u003Cbr>􀂆 The member has chronic pain\u003Cbr>􀂆 The member has pain associated with end-of-life care or palliative care\u003Cbr>􀂆 The member has pain associated with sickle cell anemia\u003Cbr>􀂆 The member resides in a long-term care facility\u003Cbr>􀂆 The member has a documented acute pain condition (e.g. , acute traumatic injury) in which treatment with other agents would cause insufficient pain control\u003Cbr>􀂆 The member requires treatment for pain related to a terminal illness |\n| --- |\n| 2. Please check ALL that apply:\u003Cbr>􀂆 The member has pain severe enough to require daily, around-the-clock, long-term opioid treatment\u003Cbr>􀂆 The member is NOT opioid naïve\u003Cbr>􀂆 At least one of the following therapies have been evaluated:\u003Cbr>• Exercise therapy , Physical therapy , Weight loss , Cognitive behavioral therapy\u003Cbr>􀂆 Non-opioid therapies have provided an inadequate response or are inappropriate\u003Cbr>􀂆 Use of an NSAID (nonsteroidal anti-inflammatory drug) would be inappropriate\u003Cbr>􀂆 The member’s history of controlled substance prescriptions has been checked using the state prescription drug monitoring program (PDMP)\u003Cbr>􀂆 The member or parent/guardian has been educated on the potential adverse effects of opioid analgesics, includingthe risk of misuse, abuse, and addiction |\n\n\n| 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 |\n| --- | --- | --- |\n| 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 |\n| 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 |\n|  |  |  |\n| 6. Does the member have pain associated with active cancer treatment or cancer not in remission? | Yes | No |\n| If YES: |  |  |\n| 6a. Please provide cancer diagnosis:   |  |  |\n|  |  |  |\n| 7. Is the member a cancer survivor being treated for chronic pain? | Yes | No |\n| If YES: |  |  |\n| 7a. Has the member completed cancer treatment? | Yes | No |\n| 7b. Is the member in clinical remission? | Yes | No |\n| 7c. Is the member under cancer surveillance only? | Yes | No |\n|  |  |  |\n| 8. Is the member currently enrolled in hospice? | Yes | No |\n| If YES: |  |  |\n| 8a. Is this medication being used to treat the member’s\u003Cbr>terminal/hospice diagnosis? | Yes | No |\n| 8b. Is this medication being used to treat a condition related to the\u003Cbr>member’s terminal/hospice diagnosis (e.g. , pain, nausea,\u003Cbr>constipation, anxiety, etc. )? | Yes | No |\n\nMedication History:  \nPlease provide any other medications that the member has tried and failed:  \n\n|  |\n| --- |\n|  |\n\nThe 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.  \nINSTRUCTIONS FOR COMPLETING THIS FORM  \n1. Submit a separate form for each medication.  \n2. Please print, type or write legi","cbCaitarh3dB4KSA","https://ap.wps.com/l/cbCaitarh3dB4KSA","pdf",203604,"English","# Member Information\n# Provider Information\n# Medication Information\n## Clinical Information\n## Medication History\n# Instructions for Completing This Form","[{\"question\":\"What information must be provided on the Medication Information section?\",\"answer\":\"The form collects drug name, drug strength, requested quantity, requested day supply option, directions, and diagnosis/ICD-10 code(s).\"},{\"question\":\"What clinical criteria are checked to support opioid authorization?\",\"answer\":\"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.\"},{\"question\":\"Where and how should the completed form be submitted?\",\"answer\":\"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.\"}]","Medication Prior Authorization Form - Opioids - Complete and fax to 1-866-240-8123 | PDF",1789633777]