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Express scripts prior provigil form 2026
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- Click ‘Get Form’ to open the express scripts prior provigil form in the editor.
- Begin by filling out the Prescriber Information section. Enter your name, DEA/NPI number, phone number, and address accurately.
- Next, complete the Patient Information section. Provide the patient's first and last name, ID number, date of birth, and contact details.
- Indicate the primary diagnosis by selecting from the provided options. Ensure you include the ICD code for accurate processing.
- Specify which drug and strength is being requested by checking the appropriate box for Nuvigil or Provigil.
- Fill in directions for use clearly, indicating frequency and quantity as needed.
- Complete the clinical assessment questions thoroughly to provide necessary context for approval.
- Finally, ensure all sections are filled out before signing and dating the form at the bottom.
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express scripts prior authorization form 2019
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