Modafinil (Provigil) - Medical Necessity Request Form

ADVERTISEMENT

Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
Horizon NJ Health
Modafinil (Provigil) – Medical Necessity Request
Diagnosis Information (please indicate diagnosis and answer related questions):
□ Narcolepsy/Idiopathic Hypersomnia
□ Obstructive sleep apnea/hypopnea syndrome (OSAHS)
a. Has the member been on Continuous Positive Airway Pressure (CPAP) for at least 3 months? Yes or No
b. Is the member still symptomatic? Yes or No
c. Will the member continue to use CPAP with Provigil? Yes or No
□ Shift work sleep disorder (SWSD)
a. Has the member been symptomatic for at least 3 months? Yes or No
b. Does the member work at least 5 night shifts per month? Yes or No
□ Fatigue
a. Is the fatigue associated with either Multiple Sclerosis, Depression or Cancer? Yes or No (For Depression
or cancer, please answer the questions under depression or cancer, respectively)
- If no, what is the fatigue associated with or due to?
____________________________________________________________________________
□ Multiple Sclerosis
a. Does the member have associated fatigue? Yes or No
□
Attention deficient hyperactivity disorder (
Attention deficient disorder (
ADHD)/
ADD)
a. Can the member try a formulary ADHD medication? Yes or No NOTE: Formulary medications include:
methylphenidate immediate-/extended-release preparation, immediate-release dexmethylphenidate, mixed-salts
amphetamine immediate-/extended-release preparation, dextroamphetamine immediate-/sustained-release,
methamphetamine, Strattera, immediate release guanfacine, immediate release clonidine.
- If yes, please call the formulary ADHD medication prescription into the member’s pharmacy.
- If no, please provide the clinical reason why a formulary medication cannot be tried?
_________________________________________________________________________________
b. What medication(s) has the member tried for ADHD/ADD?
_____________________________________________________________________________________
□ Cancer
a. Does the member have associated fatigue? Yes or No
b.What is the severity of the fatigue?
□ Mild
□ Moderate
□ Severe
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office
1 of 2
Rev. 03/16
HNJH Fax #: 888-567-0681
Page

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Medical Necessity Request Form Medical Necessity Request Form Medical
Medical Necessity Request Form Medical Necessity Request Form Medical
Medical Necessity Request Form Medical Necessity Request Form Medical
Medical Necessity Request Form Medical Necessity Request Form Medical
Hemophilia Medications - Medical Necessity Request Form Hemophilia Medications - Medical Necessity Request Form Medical
Ezetimibe (zetia) - Medical Necessity Request Form Ezetimibe (zetia) - Medical Necessity Request Form Medical
Imiquimod (aldara) - Medical Necessity Request Form Imiquimod (aldara) - Medical Necessity Request Form Medical
Infant Formulas - Medical Necessity Request Form Infant Formulas - Medical Necessity Request Form Medical
Nutritional Supplements- Medical Necessity Request Form Nutritional Supplements- Medical Necessity Request Form Medical
Omalizumab (xolair) - Medical Necessity Request Form Omalizumab (xolair) - Medical Necessity Request Form Medical

Related Categories

Parent category: Medical
Download
Go
Page of 2