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2019-06-22 at 08:24PM UTC #280480

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The member has been screened for substance abuse/opioid vicodin dependence .
Is the opioid regimen being used in combination with buprenorphine vicodin containing products for opioid dependence?  Yes  No 3 .
What is the total vicodin coupon vicodin mechanism of action quitting vicodin tips vicodin dangers vicodin dosage daily desired morphine milligram equivalent (MME) requested for the member? _________________________________ 4 .
What is the member’s diagnosis associated with the need for pain vicodin management with opioids? (Document the diagnosis)______________ ______________________________________________________________________________________________________________ 5 .
Has the state’s prescription drug monitoring program vicodin (PDMP) been reviewed for this member?  Yes  No  None in state What other controlled substances is the member currently receiving? ______________________________________________________ _____________________________________________________________________________________________________________ 6 .
Has the member tried and failed a non-opioid pain medication(s)?  Yes  No If yes, document the name of the medication(s) and date of vicodin trial: Medication:____________________________________________ Date of trial: ____________________ 7 .
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