Stimulants and Related Agents - Analeptics (prior authorization)
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Prior authorization form and criteria for stimulant and related analeptic medications (examples: Provigil, Nuvigil, Sunosi, Wakix) for Geisinger Health Plan members; applies to prescribers requesting new or renewal coverage for these drugs.
No material clinical or coverage changes in this revision.
Coverage Criteria Overview
Initial therapy criteria
Covered when ALL of the following are met for the indicated condition
Indication selection
- Narcolepsy: Diagnosis is consistent with current International Classification of Sleep Disorders criteria (e.g., MSLT, overnight PSG, hypocretin-1 concentration, clinical assessment).
- Shift work sleep disorder: Diagnosis is consistent with current International Classification of Sleep Disorders criteria (e.g., shift work schedule, sleep log & actigraphy monitoring, other causes ruled out, clinical assessment).
- OSAHS: Diagnosis is consistent with current International Classification of Sleep Disorders criteria AND either: tried and failed CPAP while adherent to treatment to resolve daytime sleepiness (document CPAP adherence) OR cannot use CPAP (reason documented) OR tried and failed an oral appliance to resolve daytime sleepiness. Objective support may include Epworth Sleepiness Scale >10 or MSLT <8 minutes.
Document CPAP adherence and reasons if CPAP cannot be used.
- MS-related fatigue: Patient is currently receiving treatment for multiple sclerosis OR document reason not receiving MS treatment.
- Non-preferred agent requirement: For a NON-PREFERRED analeptic: history of trial and failure of, or contraindication or intolerance to, preferred analeptic agents per the PDL must be documented.
Refer to the PDL for preferred vs non-preferred agents.
The form does not list blanket exclusions by name, but it implicitly requires documentation that meets diagnostic and treatment-trial expectations; requests lacking that documentation are not supported. Specifically, if the submission does not include evidence that the diagnosis is consistent with current International Classification of Sleep Disorders criteria (e.g., MSLT, overnight PSG, hypocretin‑1 concentration, clinical assessment) or, for OSAHS, documentation of CPAP trial and adherence or reason CPAP cannot be used, the request would be considered incomplete and may be denied.
Although the form does not enumerate explicit non‑coverage scenarios, providers must supply the required objective testing and trial information to demonstrate medical necessity. For non‑preferred analeptics, the form requires documentation of a history of trial and failure, or a contraindication or intolerance to preferred agents. Similarly, failure to provide objective measures (for example, Epworth Sleepiness Scale >10 or MSLT <8 minutes for OSAHS) or CPAP adherence/trial data will leave the request unsupported.
Initial Therapy — Indication-specific Requirements
Initial therapy
Initial request criteria by indication
Diagnosis must be consistent with current International Classification of Sleep Disorders criteria and supported by appropriate testing and documentation (e.g., MSLT, PSG, sleep logs, actigraphy).
Renewal / Continuation Requirements
Provider Actions and Documentation Requirements
Prior authorization required — use Geisinger form (effective 1/6/2025)
Prior authorization is required for stimulants and related analeptics; use the Geisinger prior authorization form (form effective 1/6/2025) for new and renewal requests and submit required clinical documentation.
Document prior trial/failure or contraindication for non-preferred agents
For any request for a non-preferred analeptic, document a history of trial and failure of — or a documented contraindication or intolerance to — preferred analeptic agents listed on the PDL for the beneficiary's diagnosis; this requirement applies to both initial and renewal requests.
- Refer to the Preferred Drug List at https://papdl.com/preferred-drug-list for which agents are preferred.
Required submission materials — completed form and supporting documentation
Submit the completed Geisinger prior authorization form with required clinical documentation including the diagnosis and DX code, a current complete medication list, documentation of trials/failures (e.g., CPAP adherence, objective sleep testing results), prescriber signature, and any other applicable sections completed.
- Include diagnosis and required DX code (form field: DX code (required)).
- Provide documentation of CPAP adherence or reason CPAP cannot be used, Epworth Sleepiness Scale or MSLT results when applicable.
- Send via PromptPA (https://ghp.promptpa.com) or fax completed form and documentation to Geisinger Health Plan at 570-271-5610.
Incomplete diagnostic documentation may trigger denial
Failure to document a diagnosis consistent with current International Classification of Sleep Disorders criteria or to provide required objective testing (e.g., MSLT, PSG, actigraphy, sleep logs) or CPAP/adherence documentation for OSAHS may result in denial of the request.
- For narcolepsy, shift work sleep disorder, and OSAHS, ensure documentation meets International Classification of Sleep Disorders criteria (examples listed on the form).
- For OSAHS, include CPAP adherence documentation, objective measures (Epworth >10 or MSLT <8) or documented reason CPAP cannot be used.
Required Coding and Objective Measures
| DX code (required) | Requester must provide the beneficiary diagnosis code |
Objective Testing and Definitions
Step Therapy / Prior Trial Requirements
| Step | Requirement | Notes |
|---|---|---|
| 1 | ||
| Required prior trial or documentation of contraindication/intolerance to preferred analeptic agents per the PDL | ||
| For both initial and renewal requests when the drug is non‑preferred: provider must document history of trial and failure, or a contraindication or intolerance to preferred analeptic Stimulants and Related Agents (see the Geisinger PDL). |
Background
Analeptic stimulants are utilized to manage excessive daytime sleepiness across several conditions, including narcolepsy, shift work sleep disorder, obstructive sleep apnea/hypopnea syndrome (when CPAP/oral appliance has failed or cannot be used), and fatigue related to multiple sclerosis. The form requests objective testing and documentation (for example, MSLT, PSG, sleep logs, or other measures) and adherence or trial information to support that the medication is medically necessary.
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