Note to Reviewer CA-27

Authorization Request Forms/Certification/Letter of Medical Necessity

1240-0055

May 2017

NOTE TO REVIEWER

Justification for nonmaterial change:

In order to provide improved guidance to respondents, OWCP seeks to make two clarifying changes to the Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications, Form CA-27.

1. Change item 39 on page 3, to clarify and to avoid duplicative responses, to state that opioids should only be listed in item 21.

The first sentence of item 39 currently begins:

“If the requested opioid medication is prescribed in a compounded drug, complete the following for active and inactive ingredient in the compounded drug;.”

The revised statement would begin:

“If the requested opioid medication is prescribed in a compounded drug list opioid ingredients in box 21, complete the following for all other non-opioid active and inactive ingredients in the compounded drug;.”

The instructions on the form are similarly revised on page 5.

Note: The required information on opioids should be supplied in Part C and in items 28-38 of Part D, Certificate of Medical Necessity. Opioids should not be relisted in item 39, which should only list non-opioid compounded active and inactive ingredients. Therefore, the form and instructions for item 39 are revised to state that item 39 should be completed for each active and inactive NON-OPIOID ingredient in the compounded drug. Under Part D, Certificate of Medical Necessity:

2. On page 4, under Part C, OWCP seeks to provide additional instruction on agency restrictions

The statement currently reads:

“PART C - Opioid Medication Information. Note that OWCP generally limits opioid medications to no more than 2 concurrently prescribed.”

The revised statement would read:

“PART C - Opioid Medication Information. Note that OWCP generally limits opioid medications to no more than 2 concurrently prescribed. Additionally, there are restrictions on more than one medication within the same therapeutic class.”

3. The paper version of form CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications was approved by OMB. As noted in the Supporting Statement with the original submission (item 3), DFEC is now requesting approval for an electronic version of this form. See attached screen shot.

The form will be found on our contracted medical vendor’s website.

The treating physician will have the ability to electronically submit the form to our contracted medical vendor.  The electronic version is in the same format as the paper form.