Express Scripts Prior Authorization Form - Nuvigil And Provigil Page 2
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1
2 Yes
No
N/A
4. If the diagnosis is fatigue or sleepiness associated with HIV infection OR chronic use of narcotic
analgesics, has the patient tried one CNS stimulant (for example: methylphenidate [Ritalin],
dextroamphetamine [Dexedrine, Dextrostat])?
If yes, please document CNS stimulant tried: _____________________________________
__________________________________________________________________
Yes
No
N/A
5. If the diagnosis is ADHD/ADD, has the patient tried two alternative medications for
ADHD/ADD? Alternatives must be from two different classes as follows:
1.
Methylphenidate products
2.
Amphetamines
3.
Strattera (atomoxetine)
4.
Wellbutrin (bupropion)
5.
TCAs (tricyclic antidepressants)
6.
Alpha-agonists (e.g., Kapvay, Intuniv)
Please document alternative medications tried: ____________________________________
__________________________________________________________________
Yes
No
N/A
6. If the diagnosis is adjunctive/augmentation treatment of depression in adults, is the patient
concurrently receiving other medication therapy for depression?
If yes, please document other drug therapy: _________________________________________
__________________________________________________________________
Yes
No
N/A
7. If the diagnosis is idiopathic hypersomnia, has the diagnosis been confirmed by a sleep
specialist physician or at an institution that specializes in sleep disorders (e.g., sleep center)?
Are there any other comments, diagnoses, symptoms, and/or any other information the
physician feels is important to this review?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Prescriber Signature: __________________________________________Date: ____________________
Office Contact Name: ___________________________ Phone Number: __________________________
Based upon each patient’s prescription plan, additional questions may be required to complete the prior authorization process. If you have any questions
about the process or required information, please contact our prior authorization team at the number listed on the top of this form.
Prior Authorization of Benefits is not the practice of medicine or a substitute for the independent medical judgment of a treating physician. Only a treating
physician can determine what medications are appropriate for the patient. Please refer to the applicable plan for the detailed information regarding
benefits, conditions, limitations, and exclusions.
The document(s) accompanying this transmission may contain confidential health information. This information is intended only for the use of the individual
or entity named above. 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 received this information in error, please notify the sender immediately and arrange for the
return or destruction of the documents.
Nuvigil_Provigil: F-14
4.2.2013
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