Form 1353, OxyContin Standard PA Addendum (Medicaid)

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Effective Date
05/2018
Document
1353.pdf (78.79 KB)

Instructions

Update: 5/2018

 

Purpose

For prescribing providers to request pharmacy prior authorization for Oxycontin® (oxycodone ER).

When to Prepare

 

Detailed Instructions

  • Staff sends the form to the Medicaid-enrolled pharmacy, who then forwards the completed form by fax.

Transmittal

  • Fax: 866-469-8590

Questions