L&I limits opioid prescriptions from dental providers to a 3-day supply, and Washington dentists use this one-page form to request an exception for post-surgical pain on a workers' compensation claim. The dentist names the dental procedure, attaching the notes, sets out the proposed pain plan with drug, dose, instructions and quantity, and confirms checking the Prescription Monitoring Program.
The prescribing dentist completes and signs it, adding a phone number.
Download the current version from the source each time; forms change without notice.
Exception to Three-Day Limit of Opioids for Dental Procedures Prior Authorization Request
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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Up to a 3-day supply. L&I's pharmacy payment policy limits opioid prescriptions from dental providers to a maximum 3-day supply. To cover more for post-surgical pain, submit this exception request with the procedure notes and the proposed pain management plan.
You confirm checking Washington's Prescription Monitoring Program to verify the worker is not receiving opioids or sedatives from other prescribers, and if they are, that you contacted those prescribers to coordinate care. If you check No, the form asks you to check the PMP before proceeding.