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Opioid Analgesic Treatment Worksheet Final 022317

Opioid Analgesic Treatment Worksheet Final 022317 2026

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The document is an Opioid Analgesic Treatment Worksheet issued by Aetna Better Health of Louisiana, designed for healthcare providers to request prior authorization for opioid medications. It outlines the necessary information required for medication requests, including patient details, treatment history, and prescriber attestations. The form specifies criteria for approval based on the patient's condition, previous treatments attempted, and guidelines for both short-acting and long-acting opioids. It also includes sections specific to various Medicaid plans in Louisiana and emphasizes the importance of monitoring and assessing risks associated with opioid use.

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Click ‘Get Form’ to open the Opioid Analgesic Treatment Worksheet Final 022317 in our editor.
Begin by filling in the recipient's name, policy ID number, and date of birth in the designated fields. This information is crucial for identifying the patient.
Next, provide details about the prescriber, including their name, specialty, Medicaid provider ID or NPI number, and contact information. Ensure accuracy for seamless communication.
Indicate whether this request is for a quantity limit override and specify the drug information. Fill out the drug name, dosage form, strength, and directions clearly.
Complete the treatment information section by selecting whether it’s for an acute or chronic condition and providing relevant diagnoses along with their ICD codes.
Finally, review all sections for completeness before submitting. Use our platform's features to save your progress and ensure all required fields are filled out correctly.

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