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The member has been hycet screened for substance abuse/opioid dependence .
Is the opioid regimen being used in combination with buprenorphine containing hycet products for opioid dependence? Yes No 3 .
What is the total daily desired morphine milligram equivalent (MME) requested for the member? hycet _________________________________ 4 .
What is the member’s diagnosis associated with the need for pain management with opioids? (Document the diagnosis)______________ ______________________________________________________________________________________________________________ Has the state’s prescription drug monitoring program (PDMP) been reviewed for this member? Yes No None in state What other controlled substances is the hycet member currently receiving? ______________________________________________________ _____________________________________________________________________________________________________________ 6 .
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