What the opioid request is for
WCB Nova Scotia assigns each claim a drug formulary based on the nature of the injury. Opioid coverage is time-limited, monitored through the Nova Scotia Prescription Monitoring Program, and needs special authorization for longer-term use. This form is the request for that authorization. Non-opioid drugs have their own form, and brand-name drugs where a generic exists use the Mandatory Generic Exemption Request.
Who completes it
The prescriber completes every section and signs it. The Substance Abuse Assessment Form and the opioid treatment agreement are separate documents. WCB publishes the agreement for you and the worker to sign, and this form asks you to confirm it’s done.
How to fill in the request
Worker and injury information
Enter the claim number, the worker’s name, date of birth, address and health card number, then the date of injury, diagnosis and comorbid conditions. The form notes that for a sprain or strain, opioids beyond the acute phase are rarely indicated, so explain why one is needed for a soft tissue injury.
Treatment plan
Give the product and strength, directions, start date and expected duration. State the treatment goals and progress, and the rationale for ongoing use other than pain control. List the medications already tried for this condition with dosage, duration, outcome and whether they’re ongoing. This list is mandatory. Add the non-drug therapies tried.
Response to opioids
Skip this section for a first start of opioids. Otherwise, give the weekly average function and pain scores since starting, each from 0 to 10, and say whether function and pain have improved overall. If not, explain the rationale for continuing and your plan, such as a dose adjustment or a taper schedule.
Function, adverse effects and psychosocial factors
Describe your plan to increase the worker’s function. Say whether the worker has had adverse effects from opioids, now or in the past, and how you’re managing the risk. Say whether a pre-existing or chronic psychosocial component is involved and how it’s being treated.
Substance abuse assessment and agreement
Indicate whether the Substance Abuse Assessment Form has already been submitted, and add any update on risk. Confirm the opioid treatment agreement and give the date of the next follow-up visit. Then add your name, address, phone, fax, licence number, signature and date.
Common reasons it’s delayed or refused
- No Substance Abuse Assessment Form on file for a first opioid request.
- The treatment agreement question left unanswered.
- The medications tried section left blank.
- A renewal with no function and pain scores, or no plan when function hasn’t improved.
- The wrong claim number, when the worker has more than one claim.
Submitting and who pays
Fax the request to Medavie Blue Cross at (902) 496-5819 or mail it to PO Box 2200, Halifax, NS B3J 3C6. Physicians bill the form under MSI fee code WCB24, and other prescribers invoice WCB directly. If the request is approved, the worker gets a letter and the drug is covered at the pharmacy.