CurrentColorado Rocky Mountain Health PlansPolicy N/A

Wake-promoting agents prior authorization (modafinil/armodafinil and related drugs)

Form used to request initial or continuation prior authorization for wake‑promoting agents (e.g., modafinil/armodafinil and related non-preferred agents) for Colorado Rocky Mountain Health Plans members; affects prescribing providers and pharmacy/prior authorization reviewers.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyWake-promoting agents prior authorization (modafinil/armodafinil and related drugs)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form including beneficiary/prescriber/drug details, diagnosis, dosage, prior trial information for non-preferred agents, and prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9clinical/form questions for continuation therapy

8clinical screening questions for initial authorization

7items collected in beneficiary/prescriber/drug sections

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Initial authorization documentation: Provider indicates initial authorization and supplies beneficiary/prescriber/drug information and documents diagnosis of narcolepsy, shift work sleep disorder, excessive fatigue due to multiple sclerosis or myotonic dystonia, or obstructive sleep apnea/hypopnea syndrome as applicable.

Includes documentation of CPAP use for OSA and whether the agent is preferred or non-preferred (form questions 1–6).

Non-preferred agent prior trial: If prescribing a non-preferred medication, provider documents trial and failure of Provigil and Nuvigil or documents a clinical reason why preferred medications cannot be used.

Form questions 8 and 8b require trial/failure of preferred agents or a documented clinical reason for not using them.

Dosage verification: Provider indicates whether the beneficiary is receiving less than 400 mg of modafinil or less than 250 mg of armodafinil.<400 mg modafinil; <250 mg armodafinil

Form question 7 captures dosing threshold used to assess appropriateness for authorization.

Continuation therapy response: For reauthorization, provider documents a reduction in excessive daytime sleepiness from pre-treatment baseline measured by a validated scale (e.g., Epworth, Stanford, Karolinska, Cleveland Adolescent Sleepiness Questionnaire, or Visual Analog Scale).

Form continuation section question 9 and prescriber signature are required for reauthorization.

The form does not enumerate specific conditions labeled as "not medically necessary." Instead, the policy relies on required documentation: missing or incomplete information (for example, failure to indicate an appropriate diagnosis such as narcolepsy, shift work sleep disorder, obstructive sleep apnea, or to document prior trials of preferred agents when a non-preferred medication is requested) creates risk for denial. Reviewers should therefore verify that all clinical screening questions and prior-trial responses are completed before approving authorization.

Medication & Dosing References

Preferred medications referencedmixed

Provigil	preferred agent (modafinil)
Nuvigil	preferred agent (armodafinil)

Dosage thresholds referenced (context)mixed

<400 mg modafinil	dosage threshold referenced on form
<250 mg armodafinil	dosage threshold referenced on form

Dosage thresholds

Dosage thresholdsBeneficiary is asked whether they are receiving < 400 mg of modafinil or < 250 mg of armodafinil.

Threshold detail — modafinilLess than 400 mg per day

Threshold detail — armodafinilLess than 250 mg per day

Provider Requirements & Prior Authorization Workflow

Prior Authorization

Prior Authorization Required

Prior authorization is required for covered agents. Requests must include complete beneficiary, prescriber, and drug details (drug name, strength, quantity per 30 days, and requested length of therapy). Indicate whether this is an initial authorization or a reauthorization. Incomplete submissions may delay review; include prescriber NPI and requester contact phone number.

Required fields: beneficiary name, ID, DOB, gender
Prescriber NPI and requester contact (name, phone, ext)
Drug details: name, strength, quantity/30 days, length of therapy (select option or specify)
Indicate: Initial authorization? Yes/No

Documentation Required

Diagnosis and Prior Trial Documentation

Document the primary diagnosis and prior treatment trials. The prescriber must indicate the beneficiary's diagnosis (narcolepsy; excessive sleepiness associated with shift work sleep disorder; obstructive sleep apnea/hypopnea syndrome; excessive fatigue associated with multiple sclerosis or myotonic dystrophy). For obstructive sleep apnea, document CPAP use. When requesting a non-preferred medication, document trials of preferred agents (Provigil and Nuvigil) and whether the beneficiary received adequate dosing of modafinil (< 400 mg) or armodafinil (< 250 mg) where applicable.

Select applicable diagnosis: Narcolepsy / Shift Work Sleep Disorder / Obstructive Sleep Apnea / MS or Myotonic Dystrophy–related fatigue
For OSA: indicate CPAP use (Yes/No)
Indicate whether beneficiary is receiving <400 mg modafinil or <250 mg armodafinil
If requesting a non-preferred medication: document trial and failure of Provigil and Nuvigil, or provide clinical reason why preferred medications cannot be used

Documentation Required

Required Form Documentation

Use the required prior authorization form and complete all beneficiary, prescriber, drug, and clinical screening sections. For continuation requests, answer the efficacy question about reduction in excessive daytime sleepiness using a validated scale and include the prescriber's signature and date.

Beneficiary section: last name, first name, beneficiary ID, DOB, gender
Prescriber section: prescribing provider NPI, requester contact name and phone/extension, prescriber signature and date (signature mandatory)
Drug section: drug name, strength, quantity per 30 days, length of therapy (select 30/60/90/120/180/365 days or other)
Clinical screening: initial vs reauthorization; diagnosis checkboxes; CPAP use; dosing adequacy question; prior trial questions including 8b clinical justification if preferred agents not suitable
For continuation: document reduction in daytime sleepiness measured by validated scale (Yes/No)

Key Definitions

Continuation therapy

Requirement for continuationFor continuation therapy, prescriber must document clinical response — specifically reduction in excessive daytime sleepiness from pre-treatment baseline measured by a validated scale (e.g., Epworth, Stanford, Karolinska, Cleveland Adolescent Sleepiness Questionnaire, or Visual Analog Scale).

Form question referenceContinuation responses are collected by answering questions 1–9 on the continuation section of the form, with question 9 assessing reduction in sleepiness.

Prescriber signaturePrescriber signature is mandatory on the continuation form attesting to accuracy of the information provided.

Initial authorization

Definition of initial authorizationAn initial authorization is indicated by selecting 'Yes' to the 'Is this an initial authorization?' question on the clinical information section of the form.

Form locationQuestion 1 of the Clinical Information section asks whether the request is an initial authorization (Yes/No).

Action for reviewersReviewers should confirm the 'Yes' selection to identify requests as initial authorizations and ensure required initial documentation is provided.

Background

This authorization form covers wake-promoting agents for patients with: narcolepsy; excessive sleepiness associated with shift work sleep disorder; excessive fatigue related to multiple sclerosis or myotonic dystrophy; and obstructive sleep apnea/hypopnea syndrome. The form also collects CPAP use and dosing information (including whether the beneficiary is receiving <400 mg modafinil or <250 mg armodafinil) and requires documentation of prior trials of preferred agents when a non-preferred medication is prescribed. For continuation requests the form requires documentation of reduction in excessive daytime sleepiness from baseline using a validated scale.