Get Upmc Opioid Prior Authorization Form

The Upmc Opioid Prior Authorization Form is an essential document for requesting coverage of . This guide provides a clear, step-by-step approach to filling out the form online, ensuring you complete it accurately.

Follow the steps to complete the Upmc Opioid Prior Authorization Form online.

1. Press the ‘Get Form’ button to access the Upmc Opioid Prior Authorization Form and open it for editing.
2. Begin by entering the 'Office Contact' details, including the provider's specialty, first and last name, phone, and fax number. Ensure all fields are clearly filled.
3. Add patient details: name, UPMC Health Plan ID number, date of birth, and age. Complete the drug requested section by indicating the strength and frequency of administration.
4. Indicate whether it is a new medication or ongoing medication, and provide the diagnosis along with the date it was started if applicable. Specify the place of infusion.
5. Select whether the member experienced improvement while on therapy and provide necessary documentation if ongoing medication is needed.
6. Answer the screening questions regarding the patient's medical history, including acute hepatitis or liver failure, previous use of oral , opioid withdrawal status, and current use of opioids.
7. Document the patient's opioid-free period before starting and submit the required documentation of participation in management programs and results from recent drug screens.
8. For the second page, repeat the patient's details and indicate if the request is for reauthorization. Provide necessary documentation showing stabilization or participation in counseling.
9. Include any additional information that may be relevant in the provided space and make sure to review both pages for completeness.
10. Finally, save your changes, download or print the completed form, and prepare to share it as needed with UPMC Health Plan Pharmacy Services.

Complete your documentation online today to ensure a smoother authorization process.