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Pharmaceutical Clinical Justification For Workers Compensation 4909 - Oregon

Pharmaceutical Clinical Justification For Workers Compensation Form. This is a Oregon form and can be used in Medical Workers Comp .
 Fillable pdf Last Modified 4/7/2011
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Pharmaceutical Clinical Justification for Workers' Compensation Workers' Compensation Division You must complete this clinical justification form when prescribing to a patient more than a five-day supply of Celebrex®, Cymbalta®, Fentora®, Kadian®, Lidoderm®, Lyrica®, or OxyContin®, as required by OAR 436-009-0090(4). Once you complete the form, you must send it to the workers' compensation insurer. If you have questions, contact the patient's workers' compensation insurer or the Workers' Compensation Division at 503-947-7606. Prescribing provider name: Date: High-cost drug: Patient name: Workers' compensation claim no.: Some equally effective and less expensive alternative drugs: Diclofenac Sodium Flurbiprofen Meclofenamate Sodium Naproxen Ibuprofen Citalopram Hydrobromide Venlafaxine HCl Fluoxetine HCl Amitriptyline HCl Gabapentin Oxycodone Hydrocodone w/Acetaminophen Hydromorphone HCL Morphine Sulfate Oxymorphone HCl Tramadol HCI Lidocaine Oint 5% Lidocaine Cream 4% Doxepin HCl Cream 5% Carbamazepine Oxcarbazepine Amitriptyline HCI Gabapentin Morphine Sulfate Oxycodone HCI Oxymorphone HCI Tramadol HCI up to Celebrex® 98% Less per pill up to Cymbalta® 61% Less per pill up to Fentora ® 94% Less per pill up to Kadian® 63% Less per pill up to Lidoderm® 95% Less per dose up to Lyrica ® 87% Less per pill up to OxyContin ® 72% Less per pill Have you previously prescribed a lower-cost alternative drug for this patient before prescribing the brand name drug checked above? Yes Yes No No Prescribing provider's signature Will your patient need the higher-cost drug for longer than 60 days? 440-4909 (3/11/DCBS/WCD/WEB) 4909 American LegalNet, Inc. www.FormsWorkFlow.com
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