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Optumrx prior authorization form

Provigil prior authorization form optumrx 2026

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Select the requested drug Select the diagnosis below Bipolar depression Obstructive sleep apnea/hypopnea syndrome OSAHS Fatigue due to multiple sclerosis MS Narcolepsy Idiopathic hypersomnolence Shift work sleep disorder Major depressive disorder Other diagnosis Yes No Has the diagnosis of narcolepsy been confirmed by a sleep study If a sleep study has not been completed please provide justification why a sleep study would not be feasible Sleep study information If this is a reauthorization req ...

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Click ‘Get Form’ to open the provigil prior authorization form in the editor.
Begin by filling out the 'Member Information' section. Enter the member's name, insurance ID, date of birth, and contact details accurately.
Next, complete the 'Provider Information' section. Include the provider's name, NPI number, office phone, and address.
In the 'Medication Information' section, specify the medication name (Provigil), strength, dosage form, and whether you are requesting a brand version.
Proceed to answer clinical questions related to the diagnosis and treatment history. Ensure all required fields are filled out completely for a smooth review process.
Finally, review all entered information for accuracy before submitting your request via fax or online as instructed on the form.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (176 Votes)
2015	4 Satisfied (46 Votes)
2014	4.4 Satisfied (608 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I get prior authorization for Optum Rx medication?

OptumRx Prior Authorization and Exception Request Procedures Call 1-800-711-4555 to submit a verbal PA request. View and print a PA request form.

How long do prior authorizations take for Optum Rx?

Can I file an appeal if my PA is denied? Yes, you can appeal the decision. Your provider will need to fax a letter of medical necessity to: Managed Pharmacy Consultations at 561-209-5822. The appeal review takes about 24-48 hours.

What are three drugs that require prior authorization?

Drugs That May Require Prior Authorization Drug ClassDrugs in Class Epidiolex Epidiolex Erythroid Stimulants , , Procrit and Retacrit, Mircera Esbriet Esbriet Evenity Evenity243 more rows

Does modafinil need prior authorization?

Pharmacy providers are required to have a completed Prior Authorization Drug Attachment for Modafinil and Nuvigil form signed by the prescriber before submitting a prior authorization (PA) request on the Portal, by fax, or by mail. Providers may call Provider Services at 800-947-9627 with questions.

Does modafinil require prior authorization?

Submit request via: Fax - 1-855-476-4158 All requests for Provigil (modafinil) and Nuvigil () require a prior authorization and will be screened for medical necessity and appropriateness using the criteria listed below.

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How do I get my doctor to prescribe modafinil?

Start by scheduling an appointment with your primary care physician or a sleep specialist to discuss your symptoms and medical history. The doctor will evaluate whether Modafinil is appropriate for your condition and may require sleep studies or other diagnostic tests.

What does modafinil cost without insurance?

Modafinil Costs Insurance Coverage Cost FactorGeneric ModafinilBrand Name (Provigil) Cash Price (30 tablets) $50150 $8001,200 With Insurance (typical) $1050 copay $50300 copay Prior Authorization Usually required Almost always required Manufacturer Discount Limited programs Up to $400/month savings3 more rows