41991 MEDCO-32 REQUEST FOR PRIOR AUTHORIZATION OF NON-PREFERRED MEDICATION (TO BE COMPLETED ONLY BY PRESCRIBING PHYSICIAN) INJURED WORKER INFORMATION Request Date / BWC Claim Number: / Injured Worker Name: Injured Worker SSN: - Injured Worker Date of Injury: - / / PRESCRIBER INFORMATION Prescriber: Prescriber Phone: - Prescriber Fax: - - - Physician Street Address City State Zip Code NON-PREFERRED MEDICATION(S) REQUESTED AND CONDITIONS BEING TREATED (REQUIRED) Medication Name ICD-9 Code(s) ICD-9 Code Description(s) 1. 2. 1. ANALGESICS: LONG ACTING OPIOIDS (Please check all boxes that apply in this claim) SHORT ACTING OPIOIDS (Please complete and c e kte“ te” o ) h c h Oh r b x Patient has pain related to cancer and cancer is an allowed condition in the claim, OR Patient meets the criteria for utilizing prescription drugs for th t ame t fi rc b p i i a c ra c wt O i e r t n o “ t t l a ”n cod n e i h e na a e n h o State Medical Board Administrative Rules (Chapter 4731-21 of the Ohio Administrative Code), AND Patient has received clinical benefit from the current/past use of preferred short-acting opioid analgesic(s) Indicate previously prescribed opioid analgesic(s): _______________________________________________________ Other (attach additional information, if necessary): ____________________________________________________________ 2. SKELETAL MUSCLE RELAXANTS (Please check all boxes that apply in this claim): Patient has previously failed an adequate trial with at least 2 different preferred skeletal muscle relaxants. Indicate previously prescribed muscle relaxants: _________________________________________________________ 3. ANALGESICS: NSAIDS AND COX-IIs (Please check all boxes that apply in this claim): History of peptic ulcer disease History of NSAID related ulcer Presence of a hereditary or acquired coagulation defect Chronic major organ impairment History of clinically significant gastrointestinal bleeding Age 60 years of age or older Patient has previously failed an adequate trial with at least two different preferred NSAIDs Indicate previously prescribed NSAIDs: ________________________________________________________________ Concurrent therapy with drugs likely to increase risk of GI bleeding List drugs: ___________________________________________________________________________________ Signature Date Prescriber Signature (REQUIRED): Please fax completed form to: 866-213-6066 TO SPEAK TO AN ACS CUSTOMER SERVICE REPRESENTATIVE, PLEASE CALL: 1-800-OHIOBWC MEDCO-32 BWC-3932 (Rev. 02/2008) / / 41991 American LegalNet, Inc. www.FormsWorkflow.com