Express Scripts Prior Authorization Form - Nuvigil And Provigil
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1
2Prior Authorization Form
Nuvigil and Provigil
This form is based on Express Scripts standard criteria and may not be
Fax completed form to 1-877-329-3760
applicable to all patients; certain plans and situations may require
additional information beyond what is specifically requested.
If this an URGENT request, please call 1-800-753-2851
Additional forms available:
Patient Information
Prescriber Information
Patient First Name: ______________________________
Prescriber Name: _________________________________
Prescriber DEA/NPI (required): ______________________
Patient Last Name: _______________________________
Prescriber Phone #: _______________________________
Patient ID#: _____________________________________
Prescriber Fax #: _________________________________
Patient DOB: ____________________________________
Prescriber Address: _______________________________
Patient Phone #: _________________________________
State: ________________ Zip Code: __________________
Primary Diagnosis: _________________________________ ICD Code: ________________________________________
Please indicate which drug and strength is being requested:
□
□
Nuvigil 50mg Tablet
Provigil 100mg Tablet
□
□
Provigil 200mg Tablet
Nuvigil 150mg Tablet
□
Nuvigil 250mg Tablet
Directions for use (i.e. QD, BID, PRN & Qty): ______________________________________________________________________
Please complete the clinical assessment:
1. What is the indication or diagnosis?
□
Fatigue associated with HIV infection
□
ADHD/ADD
□
Fatigue associated with Multiple Sclerosis (MS)
□
Adjunctive/augmentation treatment of depression in adults
□
Fatigue or sleepiness associated with chronic use
□
Cancer-related fatigue
of narcotic analgesics
□
Excessive daytime sleepiness due to myotonic dystrophy
□
Idiopathic hypersomnia
□
Excessive daytime sleepiness in Parkinsons disease
□
Myasthenia gravis
□
Excessive sleepiness due to obstructive sleep
□
Narcolepsy
apnea/hypopnea syndrome (OSAHS)
□
Other: ___________________________________
□
Excessive sleepiness due to shift work sleep disorder (SWSD)
________________________________________
_
Yes
No
N/A
2. If the diagnosis is OSAHS, has the patient tried continuous positive airway pressure (CPAP)?
N/A
3. If the diagnosis is SWSD, please indicate how many overnight shifts the patient works per
month: _______________________________________________________________________
Nuvigil_Provigil: F-14
4.2.2013
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