Modafinil (Provigil) - Medical Necessity Request Form (Page 2 of 2) in pdf

Modafinil (Provigil) - Medical Necessity Request Form Page 2

Member Name: ______________________________ Member ID: ________________ Member DOB: ________________

Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________

Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________

Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________

□ Depression

a. Does the member have associated fatigue? Yes or No

b. Has member tried and failed an SNRI? Yes or No

- If no, Can member try an SNRI (Venlafaxine, Duloxetine)? Yes or No

- If yes, please call the prescription into the member’s pharmacy

- If no, please provide the clinical reason why

___________________________________________________________________________________

c. Has member tried and failed an SSRI? Yes or No

- If No, Can member try an SSRI (Fluoxetine, Paroxetine, Fluvoxamine, Sertraline, Citalopram,

Escitalopram)? Yes or No

- If yes, please call the prescription into the member’s pharmacy

- If no, please provide the clinical reason why

___________________________________________________________________________________

d. Will member be receiving Provigil in combination with SSRI? Yes or No

e. Does member have residual symptoms (i.e. fatigue, hypersomnolence)? Yes or No

□ Mild

□ Moderate

□ Severe

f. What is the severity of the depression?

□ Other: ______________________________________________________________

Physician office's signature*_________________________________ Print Name________________________________

*Form must be completed and signed by physician or licensed representative from the physician’s office

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Rev. 03/16

HNJH Fax #: 888-567-0681

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Modafinil (Provigil) - Medical Necessity Request Form Page 2