Provigil (Modafinil) Prior Authorization Of Benefits (Pab) Form Page 2
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2CONTAINS 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
Patient Name: ___________________________________
Patient ID#: ________________________________
Obstructive Sleep Apnea-hypopnea:
□
□
Yes
No
Patient has a diagnosis of obstructive sleep apnea-hypopnea
□
□
Yes
No
Diagnosis has been objectively confirmed by polysomnography (PSG) or home testing with portable
monitor showing one of the following:
□
Greater than 15 obstructive events (defined as apneas, hypopneas plus respiratory event related
arousal) per hour of sleep
□
Greater than 5 obstructive events per hour of sleep and patient reports any of the following:
□
Unintentional sleep episodes during wakefulness
□
Daytime sleepiness
□
Unrefreshing sleep
□
Fatigue
□
Insomnia
□
Waking up breath holding, gasping, or choking
□
Bed partner describing loud snoring, breathing interruptions or both
□
Presence of comorbid conditions including hypertension, mood disorder, cognitive dysfunction,
coronary artery disease, stroke, congestive heart failure, arterial fibrillation or type 2 diabetes
mellitus
□
□
Yes
No
Patient has an Epworth Sleepiness Scale score greater than or equal to 10, despite treatment with
continuous positive airway pressure (CPAP)
Shift-work Sleep Disorder
□
□
Yes
No
Patient has a diagnosis of shift-work sleep disorder (SWSD)
□
□
Yes
No
It has been confirmed that no other medical or mental disorder accounts for the symptoms
□
□
Yes
No
It has been confirmed that symptoms do not meet criteria for any other sleep disorder (i.e. Jet lag)
□
□
Yes
No
Symptoms have occurred for at least three months
□
□
Yes
No
Patient has excessive sleepiness or insomnia associated with a work period that occurs during the
usual sleep phase or polysomnography demonstrates loss of a normal sleep-wake pattern (such as
disturbed chronobiological rhythmicity)
9. PHYSICIAN SIGNATURE
____________________________________________________________
__________________________________________
Prescriber or Authorized Signature
Date
Prior Authorization of Benefits is not the practice of medicine or the substitute for the independent medical judgment of a treating physician. Only a treating physician can determine what
medications are appropriate for a patient. Please refer to the applicable plan for the detailed information regarding benefits, conditions, limitations, and exclusions. The submitting
provider certifies that the information provided is true, accurate, and complete and the requested services are medically indicated and necessary to the health of the patient.
Note: Payment is subject to member eligibility. Authorization does not guarantee payment.
The document(s) accompanying this transmission may contain confidential health information that is legally privileged. This information is intended only
for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other
party unless required to do so by law or regulation.
If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of
these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately and arrange for the return or
destruction of these documents.
PAGE 2 OF 2
Provigil NTL PAB Fax Form 12.09.15.doc
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