Form Frx0010 - Prior Authorization Request Form For Provigil (Modafinil)

FORM # FRX0010

Prior Authorization Request Form for Provigil (modafinil)

Member Information

Provider Information

Patient Name ____________________________ Provider Name _____________________________

Cardholder ID ___________________________ DEA Number ______________________________

Date of Birth ____________________________ Address ___________________________________

Address ________________________________ City, State and Zip ___________________________

City, State Zip ___________________________ Phone Number ______________________________

Phone Number ___________________________ FAX Number _______________________________

Pharmacy Information

Pharmacy Name___________________Address__________________Phone______________________

Criteria for Approval:

1. Provigil

100mg

200mg

2. Is the patient 18 years of age or older?

Yes

No

3. Has the patient been on Provigil therapy for the previous 6 months?

Yes

No

4. Diagnosis of Narcolepsy?

Yes

No

5. Diagnosis of obstructive sleep apnea?

Yes

No

6. Diagnosis of Shift Work Sleep Disorder (SWSD)?

Yes

No

7. Have any of the following requirements been met? Check all that apply:

Yes

No

Narcolepsy has been present for the previous 6 months

Narcolepsy confirmed in sleep studies

No other extraneous causes for excessive daytime sleepliness (i.e., depression, insufficient

leesleep syndrome, nighttime insomnia, or upper airway resistance syndrome, medication)

Patient is currently undergoing continuous positive airway pressure (CPAP) therapy

Provider Signature _________________________________________ Date ________________________

Fax completed forms to (866) 284-4509.

For Office Use Only

Date/Time Received_____________________________________________________________________

Reference Number______________________________________________________________________

Approved / Denied (Circle One) by _____________________________ Date_______________________

Date/Time Returned to Provider___________________________________________________________

_____________________________________________________________________________________

__

If you have any questions regarding this form, contact the Prior Authorization Department Toll Free at

(866) 284-4492 or FAX Toll Free at (866) 284-4509.

FOX Rx Care Utilization Management

3375-I Capital Circle NE

Tallahassee, FL 32308

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