If brand Provigil or Nuvigil is being requested, the patient meets both of the following criteria (i and ii):.Prior authorization is recommended for pharmacy benefit coverage of Nuvigil or Provigil.FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED.Yes No If yes, will the other agent be discontinued?Nuvigil/Provigil – FEP MD Fax Form Revised 2/11/2022 Send completed form to: Service provigil preauthorization Benefit Plan Prior Approval P.Provigil ® (modafinil) Prior Authorization Request Form DO NOT COPY FOR FUTURE USE.INSTRUCTIONS: Type or print clearly.Nuvigil ® (armodafinil) & Provigil ® (modafinil) Prior Authorization Request Form (Page 1 of 2) DO NOT COPY FOR FUTURE USE.Prior Authorization Form: Provigil TOG Provider - Pharmacy PA Forms -Provigil (REV 2017.PRIOR AUTHORIZATION DRUG ATTACHMENT FOR MODAFINIL AND NUVIGIL.5 STEP 4: CLINICAL PRIOR AUTHORIZATION CRITERIA 1.Yes No If yes, will the other agent be discontinued?If you have questions, please call.Author: Caroline Gregory Created Date: 12/27/2016 5:16:37 PM.(opens in new window), PDF Other ways to submit a prior authorization.An incomplete form may be returned.For shift work sleep disorder, patient must still be.) Fax completed form to: 1-800-408-2386.Has the patient completed a sleep study conducted by a sleep YesNo (not approved).Modafinil [Provigil] or armodafinil [Nuvigil]) or the provider submitted clinical rationale for not using wakefulness promoting medications Product Name: Sunosi Approval Length 12 Month(s) Therapy Stage Reauthorization Guideline Type Prior Authorization Approval Criteria.Modafinil is used to treat excessive sleepiness caused by sleep apnea, narcolepsy, or shift work sleep disorder.This form may contain multiple pages.
FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED.Please complete all pages to avoid a delay in our decision.Doses up provigil preauthorization to 400 mg/day have been well tolerated, but there is no consistent evidence that this dose confers additional benefit beyond that of the 200 mg dose.This form is for prospective, concurrent, and retrospective reviews.Member Information (required) Provider Information provigil preauthorization (required) Member Name: Provider Name:.Request for Medicare Prescription Drug Coverage Determination – Spanish.Prescriber License # (ME, OS, ARNP, PA) Prescriber Phone Number Prescriber Fax Number - -.Approval is recommended for those who meet the conditions of coverage in the Criteria and Initial/Extended Approval for the diagnosis provided.The following documentation is required for preauthorization consideration 2020 modafinil (generic Provigil®) or armodafinil (generic Nuvigil®) Prior Authorization Request Page 1 of 2 (You must complete both pages.Prior Authorization Protocol PROVIGIL (modafinil), NUVIGIL (armodafinil) NATL Draft Approved: 04.Otherwise please return completed form to: UPMC HEALTH PLAN PHARMACY SERVICES PHONE 800-979-UPMC (8762) FAX 412-454-7722.Prior Authorization Request Form.Both products are approved by the Food and Drug Administration (FDA) to improve wakefulness in patients with excessive sleepiness associated with narcolepsy, obstructive sleep apnea and shift work disorder.Provigil ® /Nuvigil ® Prior Authorization Form WVDRGSPA-105 Page 2 of 2 Rev.For example, some brand-name medications are very costly.Is the client greater than or equal to (≥) 16 years of age?For urgent requests, please call: 1-800-414-2386.Allow at least 24 hours for review.If this is an urgent request, please call Together with CCHP Pharmacy Services.Fax completed form to 1-800-357-9577 If this an URGENT request, please call 1-800-753-2851 Patient Information.Page 1 of 2 Recipient’s Medicaid ID# Date of Birth (MM/DD/YYYY) / / Recipient’s Full Name.) Fax completed form to: 1-800-408-2386.10/26/2020 Page 2 of 2 Version 1.Approval is recommended for those who meet the conditions of coverage in the Criteria and Initial/Extended Approval for the diagnosis provided.Clinical Services Fax: 1-877-378-4727 Message: Attached is a Prior Authorization request form.Prescription drug medication request form fax to 1-866-240-8123 provigil (modafinil)/nuvigil (armodafinil) prior authorization form patient information.Provigil ® (modafinil) Prior Authorization Request Form DO NOT COPY FOR FUTURE USE.Office use only: Nuvigil-Armodafinil-Provigil-Modafinil_FSP_2019Jan1-W Nuvigil® (armodafinil) & Provigil® (modafinil) Prior Authorization Request Form (Page 1 of 2) DO NOT COPY FOR FUTURE USE.If request is for Provigil, has the patient tried and failed or been determined to be intolerant of Nuvigil?An intact central alpha-adrenergic system is required for modafinil's activity Provigil® / Nuvigil® Prior Authorization Form (modafinil / armodafinil) Rational Drug Therapy Program WVU School of Pharmacy PO Box 9511 HSCN Morgantown, WV 26506 Fax: 1-800-531-7787.PRIOR AUTHORIZATION FORM ONLY COMPLETED REQUESTS WILL BE REVIEWED Drug Requested: Provigil Provigil® (modafinil)/Nuvigil® (armodafinil) Title: Microsoft Word - ah_provigil.Prior authorization is recommended for pharmacy benefit coverage of Nuvigil or Provigil.Exclusion Criteria Patient has any contraindications to the use of Provigil, Being used for an off label use for any other indication than specified.