Modafinil (Provigil), Armodafinil (Nuvigil) Prior Review/certification Faxback Form
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2MODAFINIL (Provigil), ARMODAFINIL (Nuvigil)
PRIOR REVIEW/CERTIFICATION FAXBACK FORM
INCOMPLETE FORMS MAY DELAY PROCESSING
ALL NC PROVIDERS MUST PROVIDE THEIR 5-DIGIT BCBSNC PROVIDER ID# BELOW
PRESCRIBER NAME
PRESCRIBER NPI [REQUIRED]
BCBSNC PROV ID # / TAX ID [out of state only]
CONTACT PERSON
PRESCRIBER PHONE
PRESCRIBER FAX
PRESCRIBER ADDRESS
CITY
STATE
ZIP
PATIENT NAME
BCBSNC ID
DATE OF BIRTH
GENDER
M
F
Drug and Dose Requested:_________________________
Dx Code: ___________ Patient’s Age:_____
Please answer ALL the following questions:
1. For which of the following situations is modafinil or armodafinil being prescribed? Please check at least one
and answer the associated questions, if any.
Narcolepsy - Has this diagnosis been confirmed by a sleep study (polysomnogram and multiple sleep
latency test (MSLT))?** ……………………………………………………………………….…….……….
Yes
No
Excessive daytime sleepiness due to obstructive sleep apnea/hypopnea syndrome
a. Has this diagnosis been confirmed by a sleep study (polysomnogram)?** …………………….
Yes
No
b. Will this drug be used in conjunction with continuous positive airway pressure (CPAP) therapy?
Yes
No
c. If No, is the patient a candidate for CPAP therapy? ………………………………………………….
Yes
No
Shift-work sleep disorder (SWSD)
a. Is the patient a night-shift worker? ………………………………………………………………..
Yes
No
b. Does the patient complain of persistent and frequent excessive sleepiness and/or falling asleep while at
work, which interferes with the patient’s work? …………………………………………………….
Yes
No
Idiopathic hypersomnolence - Has this diagnosis been confirmed by a sleep study (polysomnogram and/or
MSLT, as appropriate) to rule out disorders such as narcolepsy, obstructive sleep apnea or post-traumatic
hypersomnia?**…………………………………………………………………………………………..
Yes
No
Fatigue associated with multiple sclerosis
Other (Medical record documentation may be required)________________________________________
2. Does the patient have any other conditions or drug therapies (e.g., sleeping pills) which may contribute to or
worsen excessive daytime sleepiness (or night-time sleepiness for those with SWSD)? …..……..
Yes
No
3. If yes, have other conditions or drug therapies known to contribute to or worsen excessive sleepiness been
addressed and/or treated? …..…………………………………………………………………….…….…..
Yes
No
4. Please list medication(s) the patient previously tried and failed, or had an inadequate response related to this
diagnosis _______________________________________________________________________________
_____________________________________________________________________
**Please submit sleep study documentation as required above**
IF YOU ARE PRESCRIBING A QUANTITY ABOVE 2 TABLETS PER DAY OF PROVIGIL OR MODAFINIL, OR 1
TABLET PER DAY OF NUVIGIL, YOU MUST COMPLETE AND SIGN PAGE 2
Please certify the following by signing and dating below: I certify that I have been authorized to request prior review
and certification for the above requested service(s). I further certify that my patient’s medical records accurately reflect
the information provided. I understand that BCBSNC may request medical records for this patient at any time in order to
verify this information. I further understand that if BCBSNC determines this information is not reflected in my patient’s
medical records, BCBSNC may request a refund of any payments made and/or pursue any other remedies available.
Prescriber’s Signature (Required):_____________________________________Date:__________________
For BCBSNC members, fax form to 1-800-795-9403
Last Updated: June 2015
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