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1230 US Highway 11 Gouverneur, NY 13642 Phone: 1-877-635-9545 Prior Authorization Fax: 1-844-712-8129 Roxicodone (oxycodone immediate-release) Prior Authorization Request Form Member Information (required) Provider Information (required) Office Street Address: Medication Information (required) Medication Name:  Check if requesting brand  Check if request is for continuation of therapy Directions for Use: Clinical Information (required) Select roxicodone and percocet roxicodone intensol oxycodone vs generic oxycodone empty stomach oxycodone the diagnosis below:  Moderate to severe pain  Other diagnosis: Medication history [Brand Roxicodone only]: Select the medications the patient has a failure, contraindication, or intolerance to:  Codeine sulfate  Hydrocodone-acetaminophen (APAP) 300mg  Hydrocodone-APAP 325mg  Oxycodone-APAP  Hydrocodone-ibuprofen 5-200mg  Oxycodone-aspirin  Hydrocodone-ibuprofen 7 . 5-200mg  Oxycodone-ibuprofen  Hydrocodone-ibuprofen 10-200mg  Morphine sulfate Quantity oxycodone morphine oxycodone kidney oxycodone kidney roxicodone in urine roxicodone xanax oxycodone limit requests: What is the quantity requested per DAY? Does the patient’s diagnosis include malignant (cancer) pain?  Yes  No Was the medication prescribed by a pain specialist or by pain management consultation?  Yes  No Select all of the following that have been maintained and documented in chart notes:  A description of the nature and intensity of the pain  An appropriate patient medical history and physical examination  An updated, comprehensive treatment plan (the treatment plan should state objectives that will be used to determine treatment success, such as pain relief or improved physical and/or psychosocial function)  Appropriate dose escalation  Ongoing, periodic review of the course of opioid therapy  Verification that the risks and benefits of the use of the requested drug have been discussed with the patient, significant other(s), and/or Chart documentation: Will chart documentation be submitted to ProAct® with this form, confirming the above information?  Yes  No **Please note: Chart documentation of the above is required to be submitted for quantity limit requests for this drug .

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