DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Medicaid Services
Wis. Admin. Code § DHS 107.10(2)
PRIOR AUTHORIZATION DRUG ATTACHMENT FOR MODAFINIL AND NUVIGIL
Instructions: Type or print clearly. Before completing this form, read the Prior Authorization Drug Attachment for Modafinil and Nuvigil
Completion Instructions, F-00079A. Providers may refer to the Forms page of the ForwardHealth Portal at
for the completion instructions.
Pharmacy providers are required to have a completed Prior Authorization Drug Attachment for Modafinil and Nuvigil
form signed by
the prescriber before submitting a prior authorization (PA) request on the Portal, by fax, or by mail. Providers may call Provider Services
at 800-947-9627 with questions.
SECTION I – MEMBER INFORMATION
1. Name – Member (Last, First, Middle Initial)
2. Member Identification Number
3. Date of Birth – Member
SECTION II – PRESCRIPTION INFORMATION
5. Drug Strength
4. Drug Name
6. Date Prescription Written
7. Directions for Use
9. Name – Prescriber
10. National Provider Identifier – Prescriber
11. Address – Prescriber (Street, City, State, ZIP+4 Code)
12. Telephone Number – Prescriber
SECTION III – CLINICAL INFORMATION (Prescribers are required to complete Section III and either Section III A, III B, III C,
or III D before signing and dating this form.)
13. Diagnosis Code and Description
14. Is the member 16 years of age or older?
15. Is the member taking any other stimulants or related agents?
SECTION III A – CLINICAL INFORMATION FOR NARCOLEPSY WITH CATAPLEXY OR WITHOUT CATAPLEXY
16. Does the member have narcolepsy with cataplexy?
If yes, indicate in the space below the cataplexy symptoms experienced by the member and how frequently they occur.
17. Does the member have narcolepsy without cataplexy?