Free ForwardHealth Prior Authorization Drugs Attachment for Provigil, F-00079 - Wisconsin


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State: Wisconsin
Category: Health Care
Author: DHCAA-BBM
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Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms/f0/f00079.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-00079 (06/09)

STATE OF WISCONSIN DHS 107.10(2), 152.06(3)(h), Wis. Admin. Code DHS 153.06(3)(g), 154.06(3)(g), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION DRUG ATTACHMENT FOR PROVIGIL
Instructions: Print or type clearly. Refer to the Prior Authorization Drug Attachment for Provigil Completion Instructions, F-00079A, for more information. SECTION I -- MEMBER INFORMATION 1. Name -- Member (Last, First, Middle Initial) 2. Member Identification Number SECTION II -- PRESCRIPTION INFORMATION 4. Drug Strength (Check One) 100 mg 200 mg 6. Refills 7. Directions for Use 8. Name -- Prescriber 10. Address -- Prescriber (Street, City, State, ZIP+4 Code) 9. Prescriber National Provider Identifier 11. Telephone Number -- Prescriber 5. Date Prescription Written 3. Date of Birth

SECTION III -- CLINICAL INFORMATION (Providers are required to complete Section III and either Sections IIIA, IIIB, IIIC, or IIID before signing this form.) 12. Diagnosis Code and Description 13. Is the member at least 16 years old? 14. Is the member taking any other stimulants? SECTION III A -- CLINICAL INFORMATION FOR NARCOLEPSY 15. Does the member have a diagnosis of Narcolepsy? 16. Has the member had a Polysomnogram (PSG)? 17. Has the member had a Multiple Sleep Latency Test (MSLT)? The results from the PSG and MSLT must be submitted with this PA request for consideration. SECTION III B -- CLINICAL INFORMATION FOR OBSTRUCTIVE SLEEP APNEA / HYPOPNEA SYNDROME 18. Does the member have a diagnosis of Obstructive Sleep Apnea / Hypopnea Syndrome (OSAHS)? 19. Has the member had a Polysomnogram (PSG)? 20. What is the member's Apnea-Hypopnea Index (AHI)? 21. Has the member tried Continuous Positive Airway Pressure (CPAP)? The results from the PSG must be submitted with this PA request for consideration. Continued Yes Yes Yes No No Yes Yes Yes No No No Yes Yes No No

Events / Hour No

PRIOR AUTHORIZATION DRUG ATTACHMENT FOR PROVIGIL F-00079 (06/09)

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SECTION III C -- CLINICAL INFORMATION FOR SHIFT WORK SLEEP DISORDER 22. Does the member have a diagnosis of shift work sleep disorder? 23. Is the member a night-shift worker? 24. Is the member taking any hypnotics, sleep aids, or other medications that can cause sleepiness? 25. State the member's employer and weekly work schedule. Yes Yes Yes No No No

SECTION III D -- CLINICAL INFORMATION FOR ATTENTION DEFICIT DISORDER 26. Does the member have a diagnosis of Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD)? 27. Does the member have a medical history of substance abuse or misuse? If yes, explain in the space provided. Yes Yes No No

28. Does the member have a serious risk of diversion? If yes, explain in the space provided.

Yes



No

29. Has the member experienced a treatment failure or a clinically significant adverse drug reaction with Strattera?

Yes



No

If yes, list the dates taken and the reason(s) for discontinuation.

SECTION IV -- AUTHORIZED SIGNATURE 30. SIGNATURE -- Prescriber 31. Date Signed

SECTION V -- ADDITIONAL INFORMATION 32. Additional diagnostic and clinical information explaining the need for the drug requested may be included below.

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