Long-Acting Opioids for Pain

Long-acting opioids are subject to prior authorization.

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* Required Field

Enter Patient Information

  • Drug Name: *
  • Patient First Name: *
  • Patient Middle Initial:
  • Patient Last Name: *
  • Date of Birth: *
  • Patient Group ID: *
  • ICD-10 Diagnosis Codes: *
  • Diagnosis Codes must be 3-8 characters with NO decimals
    Codes must be 3 - 8 characters and no decimals.
  • Has the patient been using samples?
  • Yes No
  • Dose and Directions: *

* Required Field

Enter Provider Information

  • Provider ID OR NPI: *
  • Provider's Name: *
  • Physician's Specialty: *
  • Street Address: *
  • City: *
  • State: *
  • ZIP Code: *
  • Email Address:
  • Phone Number:
  • Enter a 10 digit phone number.
  • Fax Number:
  • Enter a 10 digit phone number.
  • Contact First Name: *
  • Contact Last Name: *
  • Contact Email Address: *
  • Contact Phone Number: *
  • Contact Phone Ext:
  • Contact Fax Number: *

Has the patient had an opioid prescription in the last 120 days? *

  • Yes
  • No

Is the patient receiving hospice care, end-of-life care, or palliative care? *

  • Yes
  • No

Does the patient have a diagnosis of cancer? *

  • Yes
  • No

Is the patient opioid naive? *

  • Yes
  • No

Does the patient have a concurrent prescription for a short-acting opioid? *

  • Yes
  • No

If yes, what is the drug and dose? *

Have non-opioid therapies been optimized? *

  • Yes
  • No

If yes, please list non-opioid therapies that have been optimized. *

Has prescribing physician checked any appropriate Prescription Drug Monitoring Program (PDMP)? *

  • Yes
  • No

Comments:

Has prescribing physician discussed risks and benefits of opioid therapy? *

  • Yes
  • No

Does prescribing physician have a treatment plan (including goals for pain and function) in place, including regularly scheduled reassessments? *

  • Yes
  • No

If you have any additional information pertinent to this patient's therapy, please specify.

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Blue Cross and Blue Shield of Kansas City
Pharmacy Services
P.O. Box 412735
Kansas City, MO 64141-2735

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Revision Date 05/26/20

Member Prefix

Your prefix is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

ID Number

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Suffix

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.

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