CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Armodafinil & Modafinil Prior Authorization Request Form

A prior authorization request form for armodafinil and modafinil used by OptumRx (for Blue Cross Blue Shield - South Carolina) to collect provider, patient, medication, and clinical information to support PA determinations (e.g., narcolepsy, shift work disorder, OSA, MS-related fatigue). It specifies required fields and states requests may be denied if required information is not received.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyArmodafinil & Modafinil Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeInformational (form)

Effective Date

Next Review Date

Key ActionProviders must complete and submit the Armodafinil & Modafinil Prior Authorization Request Form (or submit via CoverMyMeds at go.covermymeds.com/OptumRx) and include all required information; requests may be denied unless all required information is received.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage or requirements.

6Clinical indication questions on form

Policy overview & scope

Payer: Blue Cross Blue Shield - South Carolina; Policy: Armodafinil & Modafinil Prior Authorization Request Form. This PA request form, used by OptumRx (in partnership with CoverMyMeds), is designed to collect provider, patient, medication, and specific clinical information to support prior authorization determinations for armodafinil and modafinil (for examples: narcolepsy, shift work disorder, obstructive sleep apnea, MS-related fatigue). The form specifies required fields and notes that requests may be denied unless all required information is received.