Provigil (Modafinil) Prior Authorization Of Benefits (Pab) Form

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CONTAINS CONFIDENTIAL PATIENT INFORMATION
Provigil (modafinil)
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
1. PATIENT INFORMATION
2. PHYSICIAN INFORMATION
Prescribing Physician: ____________________________
Patient Name: _______________________________
Physician Specialty:
____________________________
Patient ID #:
_______________________________
Physician Phone #:
_____________________________
Patient DOB: _______________________________
Physician Fax #:
_____________________________
Date of Rx:
_______________________________
Physician Address:
_____________________________
Patient Phone #: ____________________________
Physician DEA:
____________________________
Patient Email Address: ________________________
Physician NPI #:
_____________________________
Physician Email Address: ___________________________
3. MEDICATION
4. STRENGTH
5. QUANTITY PER 30 DAYS (subject to qty limits)
________________
__________________________________
Provigil (modafinil)
6. DIAGNOSIS: ___________________________________________________________________________________
CHECK ALL BOXES THAT APPLY
7. APPROVAL CRITERIA:
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.
Please indicate patient’s age: _______
Narcolepsy type 1 (narcolepsy with cataplexy):
Yes
No
Patient has a diagnosis of Narcolepsy type 1 (narcolepsy with cataplexy)
Yes
No
Diagnosis has been confirmed by the presence of daily periods of irrepressible need to sleep or
daytime lapses into sleep occurring for at least 3 months
Diagnosis has been confirmed by clear cataplexy (defined as “more than one episode of generally
Yes
No
brief [<2 min] usually bilaterally symmetrical, sudden loss of muscle tone with retained
consciousness”
Yes
No
Diagnosis has been confirmed by multiple sleep latency test (MSLT) showing one of the following:
mean sleep latency of less than 8 minutes with evidence of two sleep-onset rapid eye movement
periods (SOREMPs); OR at least one SOREMP on MSLT and a SOREMP (less than 15 minutes) on
the preceding overnight polysomnography (PSG)
Yes
No
Diagnosis has been confirmed by cerebrospinal fluid hypocreti-1 deficiency (less than [<] 110 pg/mL
or less than one-third of the normative values with the same standardized assay)
Narcolepsy type 2:
Yes
No
Patient has a diagnosis of Narcolepsy type 2
Yes
No
Diagnosis has been confirmed by multiple sleep latency test (MSLT) showing one of the following:
mean sleep latency of less than 8 minutes with evidence of two sleep-onset rapid eye movement
periods (SOREMPs); OR at least one SOREMP on MSLT and a SOREMP (less than 15 minutes) on
the preceding overnight polysomnography (PSG)
Yes
No
Diagnosis has been confirmed by the absence of cataplexy
Yes
No
Diagnosis has been confirmed by exclusion of alternative causes of excessive daytime sleepiness by
history, physical exam and polysomnography
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CONTINUED ON PAGE 2
Provigil NTL PAB Fax Form 12.09.15.doc

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