Free ForwardHealth Prior Authorization Drug Attachment for Suboxone and Subutex, F-00081 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-00081 (06/09)

STATE OF WISCONSIN DHS 107.10(2), 152.06(3)(h), Wis. Admin. Code DHS 153.06(3)(g), 154.06(3)(g), Wis. Admin. Code

FORWARDHEALTH PRIOR AUTHORIZATION DRUG ATTACHMENT FOR SUBOXONE AND SUBUTEX
Instructions: Print or type clearly. Refer to the Prior Authorization Drug Attachment for Suboxone and Subutex Completion Instructions, F-00081A, for more information. SECTION I -- MEMBER INFORMATION 1. Name -- Member (Last, First, Middle Initial) 2. Member Identification Number SECTION II -- PRESCRIPTION INFORMATION 4. Drug Name (Check One) 6. Date Prescription Written 8. Directions for Use 9. Name -- Prescriber 11. Address -- Prescriber (Street, City, State, ZIP+4 Code) 10. Prescriber National Provider Identifier 12. Telephone Number -- Prescriber Suboxone Subutex 5. Drug Strength (Check Strength[s]) 2 mg 7. Refills 8 mg 3. Date of Birth

SECTION IIIA -- CLINICAL INFORMATION (Required for all requests.) 13. Diagnosis Code and Description 14. Is the member at least 16 years old? 15. Does the member have a diagnosis of opioid dependence? 16. If female, is the member nursing? 17. Does the physician have a valid Drug Addiction Treatment Act (DATA 2000) waiver allowing him or her to prescribe Suboxone and Subutex for opioid dependence? If yes, enter the physician's "X" DEA number in the space provided. Yes Yes Yes Yes No No No No

18. Is the member taking any other opioids, tramadol, or carisoprodol? 19. Does the member have any untreated or unstable psychiatric conditions that may interfere with compliance? SECTION IIIB -- CLINICAL INFORMATION (Complete for Subutex request only.) 20. Is the member pregnant? 21. Does the member have a documented allergy to naloxone?

Yes Yes



No No

Yes Yes



No No Continued

PRIOR AUTHORIZATION DRUG ATTACHMENT FOR SUBOXONE AND SUBUTEX F-00081 (06/09)

Page 2 of 2

SECTION IV -- ATTESTATION The U.S. Department of Health and Human Services endorses the Federation of State Medical Boards ­ Model Policy Guidelines for Opioid Addiction Treatment. The prescribing physician agrees to follow these guidelines, including: The patient should receive opioids from only one physician and/or pharmacy when possible. The physician should employ the use of a written agreement between the physician and patient addressing issues such as: Alternative treatment options. Regular toxicologic testing for drugs of abuse and therapeutic drug levels. Number and frequency of all prescription refills. Reasons for which drug therapy may be discontinued. Continuation or modification of opioid therapy should depend on the physician's evaluation of progress toward stated treatment objective such as: Absence of toxicity. Absence of medical or behavioral adverse effects. Responsible handling of medications. Compliance with all elements of the treatment plan, including recovery-oriented activities, psychotherapy, and/or psychosocial modalities. Abstinence from illicit drug use. By signing this form, the prescribing physician agrees to follow the guidelines set forth by the State Medical Boards for Opioid Addiction Treatment. 22. SIGNATURE -- Prescriber 23. Date Signed

SECTION V -- ADDITIONAL INFORMATION 24. Additional diagnostic and clinical information explaining the need for the drug requested may be included below.

Reset Form