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For states, such as GA and AR, that have a terminal illness mandate, and for members who have a terminal illness, answer the Will the requested medication be used for the treatment of a terminal condition or associated symptoms? Yes No If “YES”, indicate the member’s estimated life expectancy: < 6 months < 24 months Less than ____ months (please specify) Continuation of therapy*,¥: Is this request for continuation of therapy? Yes No Will medical records be submitted documenting any of the information below? Yes No Has the member been on the requested medication in the last 180 days or is currently stabilized? Yes No Has the requested medication been safe and effective in treating the member's medical condition? Yes No Has the member tried another prescription drug in the same pharmacological class or same mechanism of action? Yes No Were prior medications discontinued due to a lack of efficacy or effectiveness, diminished effect, or an adverse event? Yes No Select all the applicable diagnoses below*: Cancer or end of life (< 2 years life expectancy) related pain Non-cancer or non-end of life pain Other diagnosis: ______________________________ ICD-10 Code(s): _____________________________________ Clinical information*: Is the member new to UnitedHealthcare Insurance (as evidenced by coverage effective date of less than or equal to 120 days)? Yes No Does the prescriber attest that the member has received an opioid in the past 120 days? Yes No Is the member currently exceeding 50 morphine milligram equivalent (MME) per day? Yes No If yes to the above, does the prescriber attest that the member requires more than 50 MME per day to adequately control pain? Yes No Is the requested medication being used for end of life pain including hospice care? Yes No Is the requested medication being used for palliative care? Yes No Is the requested medication being used for sickle cell anemia? Yes No Is the requested medication being used for traumatic injury? Yes No Is the requested medication being used for post-surgical procedures, excluding dental procedures? Yes No For members < 20 years of age, does the prescriber attest that the information based on the injury or surgical procedure performed, the member requires greater than a 3 days supply of short-acting opioids to adequately control pain? Yes No For members ≥ 20 years of age, does the prescriber attest that the information based on the injury or surgical procedure performed, the member requires greater than a 7 days supply of short-acting opioids to adequately control pain? Yes No Does the prescriber acknowledge that they have completed an addiction risk and risk of overdose assessment? Yes No ______________________________________________________________________________________________________________ This document and others if attached contain information that is privileged, confidential vicodin and/or may contain protected health information (PHI) .
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