Ibx Provigil Prior Authorization Form

Ibx provigil prior authorization form



Nuvigil ® (armodafinil) & Provigil ® (modafinil) Prior Authorization Request Form (Page 1 of 2) DO NOT COPY FOR FUTURE USE. statement supporting your request. Print, type or WRITE LEGIBLY and complete the form in full. Office use only: Nuvigil-Armodafinil-Provigil-Modafinil_Comm_2019Jan1-W. Provider Contract or Fee Schedule. Beginning September 1, 2015, health benefit plan issuers must accept the Texas Standard Prior Authorization Request. Member Information (required) Provider Information (required) Member Name: Provider Name:. Providers may submit requests via fax, phone or through the secure NCTracks secure provider portal. Has the patient completed a sleep study conducted by a sleep YesNo (not approved). Page 1 of 2 Recipient’s Medicaid ID# Date of Birth (MM/DD/YYYY) / / Recipient’s Full Name. An incomplete form may be returned. Provigil® / Nuvigil® Prior Authorization Form (modafinil / armodafinil) Rational Drug Therapy Program WVU School of Pharmacy PO Box 9511 HSCN Morgantown, WV 26506 Fax: 1-800-531-7787. Page 1 of 2 Recipient’s Medicaid ID# Date of Birth (MM/DD/YYYY) / / Recipient’s Full Name. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED. Safety edits are guidelines. Section A – Member Information First. Prior Authorization For the following drugs and/or therapeutic categories, the diagnosis, applicable lab data, and involvement of Iressa, Provigil, Retin-A, Tracleer Managed Prescription Drug. Office use only: Nuvigil-Armodafinil-Provigil-Modafinil_Comm_2019Jan1-W. Please complete this. For urgent requests, please call: 1-800-414-2386. Prior Authorizations. Prior approval (PA) is required for certain drugs prescribed to N.C. Insurance policies have their limitations and, in some cases, a physician must complete and submit the SilverScript prior authorization form in order to get approval for the drug they intend to prescribe to their patient eviCore Utilization Management prior authorization list As part of Moda Health’s efforts to provide its plan holders with access to high-quality, cost-effective care, Moda has partnered with eviCore Healthcare to assist with managing and administering benefits through the Advanced Imaging and Musculoskeletal Utilization Management programs MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: SilverScript Insurance Company Prescription Drug Plan P.O. Prior approval (PA) is required for certain drugs prescribed to N.C. procedures such as prior authorization and safety edits. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED Member Information (required) Provider Information (required) Member Name: Provider Name:. Prescriber License # (ME, OS, ARNP, PA) Prescriber Phone Number Prescriber Fax Number - -. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED Member Information. Gateway Health Plan Pharmacy Division Phone 800-392-1147 Fax 888-245-2049. Providers must ibx provigil prior authorization form complete a request form for all prescription drugs that require prior authorization. Form effective 1/1/20. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED Reauthorization If this is a reauthorization request, answer the following: Does the patient have pain associated with active cancer treatment, cancer not in remission, or sickle cell anemia? Keywords: Nuvigil, armodafinil, Provigil, modafinil Created Date: 2/6/2018 6:46:32 AM.