[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288977-105":53,"doc-detail-288977-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","opioid-prior-authorization-form-complete-sections-1-5","Opioid Prior Authorization Form - Complete Sections 1-5","","Opioid prior authorization request form for managed care organizations and Medicaid fee-for-service, including instructions to fax completed submissions to the number tied to the patient’s plan. The form gathers prescriber and patient demographic data, review urgency status, inpatient/discharge and pregnancy screening, medication request details by opioid type, and prior formulary trial outcomes. It also includes an exempt-patient section and prescriber attestation requirements, covering PDMP review, urine drug screening, naloxone offer, and pain management 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Học","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-07","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Where should completed opioid prior authorization forms be sent?","Question",{"text":109,"@type":110},"Fax completed forms to the number corresponding to the patient’s plan.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Which sections must be completed by all prescribers?",{"text":114,"@type":110},"All prescribers must complete SECTION 1, SECTION 2, and SECTION 3, and then complete either SECTION 4 or SECTION 5 as appropriate.",{"name":116,"@type":107,"acceptedAnswer":117},"What does SECTION 5 require for non-exempt patients?",{"text":118,"@type":110},"It requires prescriber attestation for non-exempt patients, including PDMP (CRISP) review and, depending on the subsection, urine drug screening, naloxone prescription/offer, and a patient-prescriber pain management/opioid treatment agreement.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},288977,1790147881,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":79,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":73},1374402739827,"https://ap-avatar.wpscdn.com/avatar/14000c97e7351f1a627?x-image-process=image/resize,m_fixed,w_180,h_180&k=1787885694763230660","Incomplete forms will not be reviewed  \nManaged care organizations (listed) and Medicaid fee-for-service use this form for opioid prior  \nauthorization  \nFax completed forms to the number corresponding to the patient’s plan.  \n\n| MCO and Fee-for-Service | Telephone | Fax |\n| --- | --- | --- |\n| Aetna Better Health of Maryland | 1-866-827-2710 | 1-877-270-3298 or\u003Cbr>[www.aetnabetterhealth.com/maryland](www.aetnabetterhealth.com/maryland) |\n| CareFirst Blue Cross Blue Shield Community Health Plan Maryland | 1-877-418-4133 | 1-855-762-5205 OR CVS Caremark Prior Authorization Forms | CoverMyMeds |\n| Jai Medical Systems | 1-800-555-8513 | 1-866-999-7736 OR 1-800-583-6010 |\n| Kaiser Permanente Health Choice | 1-866-331-2103 | 1-866-331-2104 |\n| Maryland Medicaid Fee-for-Service | 1-800-932-3918 | 1-866-440-9345 |\n| Maryland Physicians Care | 1-888-258-8250 | 1-833-896-0656 |\n| MedStar Family Choice | 1-877-772-6505 | 410-350-7454 |\n| Priority Partners | 1-888-819-1043 | 410-424-4607 |\n| United Healthcare Community Plan | 1-800-310-6826 | 1-866-940-7328 |\n| WellPoint Maryland | 1-833-707-0867 | 1-844-490-4871 |\n\nFor Amerigroup and UnitedHealthcare forms visit:  \n[https://health.maryland.gov/mmcp/pap/Pages/Pharmacy-Program-Forms.aspx](https://health.maryland.gov/mmcp/pap/Pages/Pharmacy-Program-Forms.aspx)  \n[All prescribers must complete SECTION 1](All prescribers must complete SECTION 1), SECTION 2, AND SECTION 3.  \nPrescribers must complete either SECTION 4 or SECTION 5 as appropriate.  \nTO AVOID DELAYS in processing this request, please ensure that contact information is accurate in case additional information is required.  \nDuration of prior authorization is determined by Medicaid fee-for-service of managed care organizations.  \nFor additional information about individual managed care organizations’ opioid-prescribing requirements, visit:  \n[https://health.maryland.gov/mmcp/pap/Pages/Pharmacy-Program-Forms.aspx](https://health.maryland.gov/mmcp/pap/Pages/Pharmacy-Program-Forms.aspx)  \nIncomplete forms will not be reviewed  \nManaged care organizations (listed) and Medicaid fee-for-service use this form for opioid prior  \nauthorization  \nFax completed forms to the number corresponding to the patient’s plan.  \n\n| SECTION 1: DEMOGRAPHICS |  |\n| --- | --- |\n| Date (mm/dd/yyyy):  \u003Cbr>Patient name:  \u003Cbr>MCO Plan ID:  \u003Cbr>MD Medicaid ID:   Date of Birth (mm/dd/yyyy) :   Name of MCO:  \u003Cbr>Prescriber Name:  \u003Cbr>Prescriber DEA\\#:   | Gender as listed by the patient: □ Male □ Female\u003Cbr>Other Insurance? :   Prescriber NPI\\#:   Phone for Prescriber:   |\n| Office Contact Name / Fax Attention to:  \u003Cbr>Office Contact Direct Phone\\#:   Office / Prescriber Fax \\#:   Facility / Clinic Name (if applicable): |  |\n\nSECTION 2: CHECK ALL THE BOXES THAT APPLY  \n􀂉 Non-Urgent Review  \n􀂉 Urgent Review: By checking this box, I certify that applying non-urgent review timeframe may lead to patient harm.  \n􀂉 Yes 􀂉 No This patient is currently an inpatient at an acute care hospital.  \n􀂉 Yes 􀂉 No Is this patient being discharged from the hospital or ED?  \n􀂉 Yes 􀂉 No Is the patient pregnant? (See references below.)  \n1. [http://www.medscape.com/viewarticle/867512](http://www.medscape.com/viewarticle/867512)  \n2. [https://www.cdc.gov/mmwr/volumes/65/wr/mm6531a2.htm](https://www.cdc.gov/mmwr/volumes/65/wr/mm6531a2.htm)  \n3. [https://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm118113.htm](https://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm118113.htm)  \nIncomplete forms will not be reviewed  \nManaged care organizations (listed) and Medicaid fee-for-service use this form for opioid prior  \nauthorization  \nFax completed forms to the number corresponding to the patient’s plan.  \nSECTION 3: USE A SEPARATE FORM FOR EACH MEDICATION BEING REQUESTED  \nSelect One: 􀂉 New Prescription 􀂉 Refill (i.e., patient has been taking medication)  \nDiagnosis:    \nSelect All That Apply: 􀂉 Immediate-Release ","cbCaipeReI6hgjoA","https://ap.wps.com/l/cbCaipeReI6hgjoA","pdf",417305,"English","# Submission Instructions\n# Section 1: Demographics\n# Section 2: Review Urgency and Clinical Questions\n# Section 3: Medication Request Details\n# Section 4: Exempt Patients Only\n# Section 5: Prescriber Attestation","[{\"question\":\"Where should completed opioid prior authorization forms be sent?\",\"answer\":\"Fax completed forms to the number corresponding to the patient’s plan.\"},{\"question\":\"Which sections must be completed by all prescribers?\",\"answer\":\"All prescribers must complete SECTION 1, SECTION 2, and SECTION 3, and then complete either SECTION 4 or SECTION 5 as appropriate.\"},{\"question\":\"What does SECTION 5 require for non-exempt patients?\",\"answer\":\"It requires prescriber attestation for non-exempt patients, including PDMP (CRISP) review and, depending on the subsection, urine drug screening, naloxone prescription/offer, and a patient-prescriber pain management/opioid treatment agreement.\"}]","Opioid Prior Authorization Form - Complete Sections 1-5 | PDF",1789634325]