Modafinil Coverage Determination
(FOR PROVIDER USE ONLY)
Customer ID:
Customer DOB: Customer Address:
Phone (Home): Phone (Cell):
NPI Number:
Provider Name: Provider Address:
Drug Name: Dosage:
Frequency: Quantity:________ Days Supply:________ Refills:_________
□
New Medication
□
Continuation
Provide Start Date--------->
MEMBER INFORMATION REQUIRED
(Please Write Legibly)
Customer Name:
PROVIDER INFORMATION REQUIRED
(Please Write Legibly)
License Number: DEA Number:
□
Do Not Substitute-Dispense As Written
Provider Specialty:
DRUG & PRESCRIPTION INFORMATION REQUIRED
(Please Write Legibly)
Provider Phone:
Please check whether this is a new medication or therapy continuation
Provider Fax:
Office Contact Name:
DIAGNOSIS INFORMATION REQUIRED
(Please Write Legibly)
List Diagnosis/ICD-10 Code(s):
If you have checked "Continuation",
Modafinil_Form
INT_19_70783 10162018
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Modafinil Coverage Determination
(FOR PROVIDER USE ONLY)
Dosage Frequency Quantity
Other Questions:
Is this request for an inpatient that is awaiting discharge?
□
YES
□
NO
Date:
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare
of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St. Louis, Inc., HealthSpring
Life & Health Insurance Company, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. The Cigna name, logos, and other Cigna marks
are owned by Cigna Intellectual Property, Inc. Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid
programs. Enrollment in Cigna-HealthSpring depends on contract renewal.
ATTENTION: PLAN REQUIRES A TRIAL OF AT LEAST 1 FORMULARY ALTERNATIVE; FAILURE TO
PROVIDE CLINICAL DOCUMENTATION SUPPORTING RATIONALE MAY RESULT IN THIS REQUEST
BEING DENIED, OR AN ADDITIONAL OUTREACH TO OBTAIN MISSING CLINICAL INFORMATION.
End DateStart Date
Provider Signature:
Armodafinil (requires prior
authorization)
Request for expedited review [24 hours]. By checking this box, I certify that applying the 72 hour
standard review time frame may seriously jeopardize the life or health of the Customer or the Customer's ability to regain maximum function
If the customer is unable to meet the criteria required for the requested medication, please provide a clinical explanation as to why an exception
should be made:
Drug Name
CLINICAL INFORMATION REQUIRED
(Please Write Legibly)
Treatment Outcome/Rationale for Non Use
SELECT ALL FORMULARY AGENTS THAT THE CUSTOMER HAS TRIED/FAILED; PLEASE INCLUDE THE DOSAGE, FREQUENCY, QUANTITY,
DURATION OF THERAPY (START AND END DATES), AND OUTCOME/RATIONALE FOR NON USE :
Modafinil_Form
INT_19_70783 10162018
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