Note to Reviewer CA-27

Authorization Request Form and Certification /Letter of Medical Necessity for Opioid Medications

1240-0055

January 2017

NOTE TO REVIEWER

Justification for nonmaterial change: The agency, in order to provide clearer guidance and greater flexibility to respondents, seeks to make the following additional changes to the form as follows:

1. Section A. In the prefatory section before Section A, revise the number of days to “60” versus “30” in the last sentence.

• Currently, the statement reads: “The form is valid and effective for up to 30 days following the date of the treating physician’s signature/certification.”

• The revised statement, should read, “The form is valid and effective for up to 60 days following the date of the treating physician’s signature/certification”.

2. Section D. For questions 28 and 31, provide a third option for the physician to respond if the physician does not have access to a PDMP program.

Currently,

• Question 28 reads, Have you accessed the requisite state Prescription Drug Monitoring Program, if available, regarding this patient’s history of controlled substances prescriptions and will you do so every month thereafter?” “Yes” or “No”

• Question 31, reads, Is the patient receiving a benzodiazepine from you or any other provide while receiving an opioid prescription?

Revision: With the third option, a physician will be able to respond, “yes” or “no” or “I do not have access to a PDMP in my state”.

3. For question 29, expand this sentence after the word “Program” in the second line.

• Currently reads, “Will you enter this prescription information into your state’s Prescription Drug Monitoring Program?

• Will you enter this prescription information into your sates Prescription Drug Monitoring Program if you are required to update it as a dispensing provider?

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