12/2010 PA009-PROV-NUVIGIL Provider Communication Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC. 03/30/2011 (modafinil/armodafinil) West Virginia Medicaid Drug Prior Authorization Form. Prior Authorization Prescriber Fax Form Provigil (Coverage Determination) This fax machine is located in a secure location as required by HIPAA regulations FLORIDA MEDICAID Prior Authorization Provigil® (modafinil) (12 Month Approval) Note: Form must be completed in full. Prior Authorization Approval Criteria. Magellanhealth. If the drug requires a prior authorization, a member's doctor will need to request and receive approval from Humana before the drug may be covered.. Prior Authorization Form Provigil®/Nuvigil® Access this PA form at https://tenncare. Provigil (Modafinil) Texas Prior Authorization Program Clinical Edits Provigil and Nuvigil Texas Prior Authorization Program Clinical Edits Provigil and. ) Fax completed form to: 1-800-408-2386. **Please note that this form is to be completed by the prescribing physician. Recommended Dosing Regimen and Authorization Limit: Drug Dosing Regimen Authorization Limit; Provigil 6059 fl prov 1010 prime therapeutics llc 12/10 provigil® / nuvigiltm prior authorization and quantity limit physician fax form. IF THIS IS AN URGENT REQUEST, Please Call UPMC Health Plan Pharmacy Services. Otherwise please return completed form to:. 1 of 2 Revision date: June 2017 Prior Authorization Conditions for Approval of Provigil® (modafinil) and Nuvigil® (armodafinil) Website form: www. Re-authorization:. 2018 modafinil (generic Provigil®) Prior provigil dextroamphetamine Authorization Request Page wikipedia provigil 1 of 2 (You must complete both pages. The criteria listed above applies to Fallon Health Plan and its subsidiaries. Com/static/docs/Prior_Authorization_Forms/TennCare_Provigil. Page 1 of 1 CMS 1/1/15. If this an URGENT request, Prior Authorization Form Nuvigil and Provigil Nuvigil 50mg Table t Provigil 100mg Table. 336 Anthem Prior Authorization Form Templates are. Program Prior Authorization/Notification – Provigil, Nuvigil Change Control 10/2014 Added coverage for adjunctive therapy for the treatment of depression PROVIGIL / NUVIGIL PRIOR APPROVAL REQUEST Attached is a Prior Authorization request form. Provigil® / Nuvigil® Prior Authorization Form (modafinil / armodafinil) Rational Drug Therapy Program WVU School of Pharmacy PO Box provigil prior authorization 9511 HSCN Morgantown, WV 26506. View, download and print Provigil (modafinil) provigil prior authorization Prior Authorization Of Benefits (pab) pdf template or form online. Provigil ® /Nuvigil ® Prior Authorization Form WVDRGSPA-105 Page 1 of provigil prior authorization 2 Rev. Modafinil (Provigil) Patients may only have a prior authorization for one of provigil secret success these medications at a time. Page 1 of 1 CMS 1/1/15. Prior Authorization Form. This form and its contents are permissible under HIPAA as the protected health. 1 of 2 Revision date: June 2017 Prior Authorization Conditions for Approval of Provigil® (modafinil) and Nuvigil® (armodafinil) Website form: www. The PA criteria will approve modafinil or armodafinil when prescribed according to product labeling for patients sixteen years and older. An incomplete form may be returned Prior Authorization Form Nuvigil and Provigil This form is based on Express Scripts standard criteria and may not be applicable to all patients; Amida Care may. Prior Authorization Criteria Form CAREMARK FAX FORM Provigil This fax machine is located in a secure location as required by HIPAA regulations This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI) PROVIGIL. OptumRx Prior Authorization Department Phone: 877-228-7909 Fax: 866-511-2202 Caterpillar Prescription Drug Benefit Page 1 of 2 2/1/15 Prescriber Information. For Provigil requests, * Requires Prior Authorization. Prior Authorization Approval Criteria. View, download and print Provigil (modafinil) Prior Authorization Of Benefits (pab) pdf template or form online. If you are requesting a quantity above 2 tablets per day of Provigil or modafinil, or 1 please ensure that a prior approval authorization has been submitted. Safety and effectiveness in. 336 Anthem Prior Authorization Form Templates are. The criteria listed above applies to Fallon Health Plan and its subsidiaries. Initial Authorization: 1 year. If you are requesting a quantity above 2 tablets per day of Provigil or modafinil, or 1 please ensure that a prior approval authorization has been submitted. For your convenience, there are 3 ways to complete a Prior Authorization.