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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Provigil NTL PAB Fax Form 12.09.15.doc