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PRIOR AUTHORIZATION DRUG ATTACHMENT FOR MODAFINIL AND NUVIGIL
3 of 4
F-00079 (01/2017)
SECTION III C – CLINICAL INFORMATION FOR SHIFT WORK SLEEP DISORDER (Continued)
29. Is the member taking CNS depressants (i.e., anxiolytics, barbiturates, or opioids)?
Yes
No
If yes, indicate the CNS depressants and daily doses.
1.
2.
3.
Are any of the above listed CNS depressants contributing to the member’s daytime
sleepiness?
Yes
No
If no, indicate how the prescriber evaluated the CNS depressants and determined they are not contributing to the member’s
daytime sleepiness.
SECTION III D – CLINICAL INFORMATION FOR ATTENTION DEFICIT DISORDER (ADD) OR ATTENTION DEFICIT
HYPERACTIVITY DISORDER (ADHD) (Complete this section only for PA requests for modafinil, if applicable.)
30. Does the member have a diagnosis of ADD or ADHD?
Yes
No
31. Has the member experienced an unsatisfactory therapeutic response or experienced a
clinically significant adverse drug reaction with at least two preferred stimulants?
Yes
No
If yes, indicate the preferred stimulants and doses, specific details about the unsatisfactory therapeutic responses or clinically
significant adverse drug reactions, and the approximate dates each preferred stimulant was taken in the space provided.
1.
2.
3.
4.
32. Has the member previously taken Strattera and experienced an unsatisfactory
therapeutic response or experienced a clinically significant adverse drug reaction?
Yes
No
If yes, indicate the specific details about the unsatisfactory therapeutic response or clinically significant adverse drug reaction
and the approximate dates Strattera was taken in the space provided.
33. Does the member have a medical history of substance abuse disorder?
Yes
No
If yes, explain in the space provided.
34. Does the member have a serious risk of drug diversion?
Yes
No
If yes, explain in the space provided.
Continued

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