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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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