[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283928-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283928-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","xtampza-er-long-acting-opioid-prior-authorization-request-form","Xtampza ER - Long-Acting Opioid Prior Authorization Request Form","","Xtampza ER Long-Acting Opioid prior authorization request form for providers to submit required member, provider, medication, and clinical details to OptumRx. The form includes member demographics and insurance identifiers, prescriber/provider contact information, and medication specifics such as strength, dosage form, and directions for use. Clinical sections cover continuation requests, selected diagnoses, end-of-life opioid use, terminal illness life expectancy, and treatment history requirements including prior opioid trials and neuropathic or fibromyalgia pathway criteria.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/xtampza-er-long-acting-opioid-prior-authorization-request-form/283928/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/xtampza-er-long-acting-opioid-prior-authorization-request-form/283928.png","ImageObject",442,249,{"name":42,"@type":43},"Caleb Sterling","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-31","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",11,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information is required to process an Xtampza ER prior authorization request?","Question",{"text":63,"@type":64},"The form requires member information, provider information, medication details, and clinical information, including diagnosis selections and relevant treatment history questions.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How does the form support prior authorization submission through CoverMyMeds?",{"text":68,"@type":64},"OptumRx partnered with CoverMyMeds to receive prior authorization requests, aiming to save time and deliver real-time determinations through the provided service link.",{"name":70,"@type":61,"acceptedAnswer":71},"What clinical details are requested for terminal illness cases?",{"text":72,"@type":64},"For eligible terminal illness mandates, the form asks whether the medication will treat a terminal condition or associated symptoms and requires selecting an estimated life expectancy range.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283928,1791370158,{"code":4,"msg":82,"data":83},"success",[84,88,93,98,103,108,112,117,122],{"id":55,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":30,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":22},962084925290,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","Please Note:  \nThe fax number for the OptumRx Prior-Authorization Request Form on the next page has changed.  \nThe new fax number is: 1-844-403-1027  \nOptumRx has partnered with CoverMyMeds to receive prior authorization requests , saving you time and often delivering real-time determinations. [Visit](Visit go.covermymeds.com/OptumRx to)[ ](Visit go.covermymeds.com/OptumRx to)[go.covermymeds.com/OptumRx](Visit go.covermymeds.com/OptumRx to)[ to](Visit go.covermymeds.com/OptumRx to) begin using this free service. Please note: All information below is required to process this request.  \nMon-Fri: 5am to 10pm Pacific / Sat: 6am to 3pm Pacific  \nXtampza ER® Long-Acting Opioid Prior Authorization Request Form (Page 1 of 2)  \nDO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED  \n\n| Member Information (required) |  |  | Provider Information (required) |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| Member Name: |  |  | Provider Name: |  |  |  |  |\n| Insurance ID\\#: |  |  | NPI\\#: |  |  | Specialty: |  |\n| Date of Birth: |  |  | Office Phone: |  |  |  |  |\n| Street Address: |  |  | Office Fax: |  |  |  |  |\n| City: | State: | Zip: | Office Street Address: |  |  |  |  |\n| Phone: |  |  | City: |  | State: |  | Zip: |\n| Medication Information (required) |  |  |  |  |  |  |  |\n| Medication Name: |  |  |  | Strength: |  | Dosage Form: |  |\n| 􀂉 Check if requesting brand |  |  |  | Directions for Use: |  |  |  |\n| 􀂉 Check if request is for continuation of therapy |  |  |  |  |  |  |  |\n| Clinical Information (required) |  |  |  |  |  |  |  |\n| For states, such as GA and AR, that have a terminal illness mandate, and for patients who have a terminal illness, please answer the following:\u003Cbr>Will the requested medication be used for the treatment of a terminal condition or associated symptoms? 􀂉 Yes 􀂉 No If “YES”, please indicate the patient’s estimated life expectancy:\u003Cbr>􀂉 Less than 6 months 􀂉 Less than 24 months 􀂉 Less than   months (please specify) |  |  |  |  |  |  |  |\n| Continuation of therapy:\u003Cbr>Is the patient established on the prescribed medication and this prescription is for continuation of therapy? 􀂉 Yes 􀂉 No |  |  |  |  |  |  |  |\n| Select all the applicable diagnoses below:\u003Cbr>􀂉 Cancer pain\u003Cbr>􀂉 Moderate to severe chronic pain that is non-neuropathic\u003Cbr>􀂉 Moderate to severe neuropathic pain or fibromyalgia\u003Cbr>􀂉 Other diagnosis:   􀂉 ICD-10 Code(s): \u003Cbr>End of life care:\u003Cbr>Is the patient receiving opioids as part of end of life care? 􀂉 Yes 􀂉 No |  |  |  |  |  |  |  |\n| For diagnosis of moderate to severe chronic pain that is non-neuropathic, please answer the following:\u003Cbr>Is the prescribed medication being used as an as-needed (PRN) analgesic? 􀂉 Yes 􀂉 No\u003Cbr>Is the prescribed medication being used for pain that is mild or not expected to persist for an extended period of time? 􀂉 Yes 􀂉 No\u003Cbr>Is the prescribed medication being used for acute pain? 􀂉 Yes 􀂉 No\u003Cbr>Is the prescribed medication being used for postoperative pain? 􀂉 Yes 􀂉 No If yes, please answer the following:\u003Cbr>􀁸 Has the patient already received chronic opioid therapy prior to surgery or is the postoperative pain expected to\u003Cbr>be moderate to severe and persist for an extended period of time? 􀂉 Yes 􀂉 No Is the patient filling the prescribed medication for the first time? 􀂉 Yes 􀂉 No\u003Cbr>Prior to the start of therapy with the prescribed medication, has the patient failed an adequate trial of a short-acting opioid? 􀂉 Yes 􀂉 No If yes, please document the name of the medication(s), dose, date, and duration of trial:\u003Cbr>Medication:   Dose:   Date of trial:   Duration of trial:   |  |  |  |  |  |  |  |\n\nThis document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI) . The Provider named above is required to safeguard PHI by applicable law. The information in this document is for the sole use of OptumRx. Proper consent to disclose PHI between these parties ha","cbCaiuAx9VpqIcQs","https://ap.wps.com/l/cbCaiuAx9VpqIcQs","pdf",450561,"English","# Member Information\n## Provider Information\n# Medication Information\n## Clinical Information\n# End of Life Care\n## Continuation of Therapy\n# Prior Trial and Failure Documentation","[{\"question\":\"What information is required to process an Xtampza ER prior authorization request?\",\"answer\":\"The form requires member information, provider information, medication details, and clinical information, including diagnosis selections and relevant treatment history questions.\"},{\"question\":\"How does the form support prior authorization submission through CoverMyMeds?\",\"answer\":\"OptumRx partnered with CoverMyMeds to receive prior authorization requests, aiming to save time and deliver real-time determinations through the provided service link.\"},{\"question\":\"What clinical details are requested for terminal illness cases?\",\"answer\":\"For eligible terminal illness mandates, the form asks whether the medication will treat a terminal condition or associated symptoms and requires selecting an estimated life expectancy range.\"}]","Xtampza ER - Long-Acting Opioid Prior Authorization Request Form | PDF",1789622607]