Prior Authorization Request (MOUD Medication)

Prior Authorization Request — MOUD Medication

Date: [Date of preparation]

Practice: [Clinic/Practice name], [Address], [Phone], [Fax]

Clinician: [Name], [Credentials] — NPI: [NPI] — DEA: [DEA number] (Include DEA only if applicable)

Patient: [Full name], DOB: [DOB], MRN: [MRN]

Insurance: [Payer name] — Member ID: [Member ID / pending] — Group ID: [Group ID] (Include group ID if available)

Request Type: [initial / renewal / dose change / formulation switch]

Urgent Request: [yes / no] — [Reason for urgency] (Include reason only if urgent)

Executive Summary

• Diagnosis: Opioid Use Disorder, [mild / moderate / severe] — ICD-10: [Code]
• Requested medication: [Generic (Brand)], [Formulation], [Dose], [Frequency]
• Medical necessity drivers:
  • [Medical necessity driver] (Include 3–6 bullets; select from: adherence barriers with daily dosing, diversion risk with take-home medication, overdose history, failed prior MOUD trials, inability to safely store medication, need for sustained therapeutic levels, safety considerations)
• Monitoring plan: [Visit frequency]; [Drug testing type and frequency]; [PDMP check cadence]
• Naloxone: [prescribed / recommended / declined / already has supply] — Overdose education: [provided / planned] — [Reason if not prescribed]
• Requested approval duration: [Duration]

Clinical Diagnosis and Severity

• DSM-5 OUD severity: [mild / moderate / severe]; [Criteria count]; [Key indicators] — Date assessed: [Date]
• Current clinical status: [active use / early remission / sustained remission / stable on MOUD]; Date: [Date]
• Last opioid use date: [Date / unknown] (Document especially for naltrexone initiation)
• Overdose history: [None known / Date(s) and brief details]
• Urine drug screen (UDS): [Result summary] — Date: [Date] (If not yet obtained: "UDS scheduled for [Date]" with reason for delay)
• PDMP review: Reviewed on [Date] — [Finding] (e.g., "no unexpected controlled substances" or coordination needed)

Requested Medication

• Name: [Generic (Brand)]
• Formulation and route: [Formulation] — Route: [SL / PO / SQ / IM]
• Dose and frequency: [Dose], [Frequency] — [Titration schedule] (Include titration if applicable)
• Quantity and duration: [Quantity requested] — Approval duration: [Duration]
• Codes: NDC: [NDC] — HCPCS/J-code: [Code] (Include only if payer requires)

Eligibility attestation: (Include only the section applicable to requested formulation)

• Extended-release buprenorphine injection: Transmucosal buprenorphine status: [currently on / test dose given and tolerated on (date)]; Observed induction: [yes / no], Date: [Date]
• Extended-release naltrexone injection: Opioid-free interval ≥7–10 days: [yes / no]; Opioid testing: [negative on (date)]; Detox status: [completed / planned for (date)]
• Methadone: Treatment setting: [OTP / Hospital]; Clinical indication over buprenorphine/naltrexone: [Indication]

Clinical Rationale

[Clinical rationale paragraph explaining: (1) the clinical problem—OUD severity and key risk factors; (2) why this specific formulation is necessary; (3) why alternatives are insufficient—adherence barriers, prior relapse with missed doses, diversion risk, safety factors; (4) how formulation supports treatment goals—reduced relapse/overdose risk, improved retention, craving stabilization. For renewals, document benefits achieved and risk of destabilization if interrupted. Limit to one short paragraph with claims supported by documented evidence.]

Prior Treatment History

• [Prior MOUD medication/formulation]: Dose: [Dose range] — Dates: [Start–Stop] — Response: [benefit / partial response / nonresponse] — Reason for discontinuation: [side effects / nonadherence / access barriers / relapse / contraindication]

(Repeat for each prior MOUD trial)

If first MOUD trial: [Rationale for selecting this medication/formulation as first-line based on patient-specific factors]

Psychosocial supports: [engaged / referred / offered / declined] — [Type of support or program] (Frame as component of comprehensive care, not prerequisite for medication)

(If records incomplete: "Prior regimen per patient report; records requested from [facility].")

Safety and Risk Assessment

Safety screening: (Include items relevant to requested agent)

• Pregnancy status: [negative / positive / not applicable] — Test date: [Date]
• Hepatic function: [LFT status or plan] (Include if clinically relevant)
• QTc risk/EKG: [Risk factors present / absent]; EKG: [Baseline date / follow-up plan] (Include for methadone or QT-prolonging combinations)
• Concomitant CNS depressants/sedatives: [present / absent] — [Coordination plan / taper plan / overdose risk counseling] (Include management if present)
• Contraindications: [None identified / Identified contraindications and management]

Adherence and diversion risk:

• Practical barriers: [Transportation / housing / work schedule / pharmacy access / other barriers identified]
• Prior adherence challenges: [Description of challenges with daily medications, or none identified]
• How requested formulation mitigates barriers: [Explanation]
• Diversion risk factors: [Objective/behavioral indicators, or none identified] — Mitigation: [Observed dosing / shorter intervals / medication counts / PDMP monitoring / random drug testing / increased visit frequency] (Pair each risk with corresponding mitigation; use objective, non-punitive language)

Monitoring Plan

• Visit frequency: [Frequency and plan for spacing as stability demonstrated]
• Drug testing: [Type], [Frequency] (Frame as clinical monitoring tool)
• PDMP reviews: [Cadence]
• Labs: [LFT schedule]; [Pregnancy testing schedule]; [EKG plan] (Include applicable items)
• Treatment goals: [Craving control, functional improvement, retention, safety goals]
• Contingency plan if incomplete response: [Dose adjustment / level of care escalation / formulation switch / additional supports]

Attestation and Contact

Attestation: The requested medication is medically necessary and part of a comprehensive treatment plan. Risks, benefits, and alternatives have been reviewed with the patient.

Signature: [Clinician name], [Credentials] — NPI: [NPI] — DEA: [DEA] — Date: [Date]

Peer-to-peer contact: [Direct phone number] — Best times: [Times available]

Attachments

• [UDS result(s), dated [Date(s)]]
• [PDMP summary, reviewed [Date]]
• [Prior treatment records from [Source/facility], [Date range]]
• [Relevant labs: [Type and Date(s)]]

(Include only applicable attachments; list with dates)