In addition to the information you provide above, please also type or print in the box below the total amount paid or
reimbursed for Provigil® or generic Provigil® (modafinil) net of co‐pays, deductibles, and co‐insurance in the following
States: Alabama, Arizona, California, District of Columbia, Florida, Hawaii, Illinois, Iowa, Kansas, Kentucky, Louisiana,
Maine, Massachusetts, Michigan, Minnesota, Mississippi, Nebraska, Nevada, New Mexico, New York, North Carolina, North Dakota,
South Dakota, Tennessee, Utah, Vermont, West Virginia and Wisconsin, other than for resale, from June 1,
2006 through September 30, 2013. You may not include amounts for which you have been reimbursed by another entity.
For mail order purchases, the state of residence of the patient is deemed to be the state in which the purchase occurred.