Armodafinil (Nuvigil) — Prior Authorization Coverage Criteria for Sleep Disorders
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Form and criteria governing prior authorization requests for armodafinil (Nuvigil) for sleep disorders (narcolepsy, obstructive sleep apnea, shift-work sleep disorder) submitted to Highmark BlueShield (Northeastern NY payer network). Affects prescribing providers requesting coverage for these medications.
No material clinical or coverage changes in this revision.
Coverage Criteria for Armodafinil (Nuvigil)
Obstructive Sleep Apnea (OSA) - coverage criteria
Covered when documentation demonstrates appropriate prior therapies and diagnostic data for OSA-related residual sleepiness:
Form requests symptoms and comorbidities to support clinical need (eg daytime sleepiness, cardiovascular disease).
Narcolepsy - coverage criteria
Covered when documentation supports narcolepsy diagnosis and baseline objective measures:
Form asks for evidence of symptom improvement if requesting reauthorization.
Shift-Work Sleep Disorder - coverage criteria
Covered when documentation supports shift-work sleep disorder:
Form requests documentation of symptom duration and exclusion of other causes.
Prior therapy requirement
Prior medication failure requirement (where applicable):
Form provides checkbox and free-text for prior medication history.
For shift‑work sleep disorder requests the form requires documentation that the member’s sleep disturbance is not attributable to another current sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder. The provider must explicitly confirm whether an alternative diagnosis or other cause has been considered and ruled out before the request can meet criteria.
Incomplete, illegible, or otherwise insufficient submissions may be returned or denied. Providers must complete all required fields on the form and include all supporting clinical documentation; follow the form instructions to print legibly and submit a separate form for each medication. Fax completed forms and documentation to 1‑866‑240‑8123 or mail to the address on the form to avoid processing delays.
Coding and Monitoring Requirements
| ICD-10 | Diagnosis and/or ICD-10 code(s) — space provided on form (specific codes not listed) |
Provider Submission and Documentation Requirements
Prior Authorization Submission
Prior authorization is required. Submit a separate, fully completed prior authorization form for each medication requested. Include prescribing physician name and full address. Fax the completed form and all clinical documentation to 1-866-240-8123 or mail to: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222. Forms must be printed, typed, or legibly written in blue or black ink.
- Submit a separate form per medication
- Fax: 1-866-240-8123
- Mail: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222
Submission Completeness
A complete submission includes all required sections of the prior authorization form and legible supporting documentation. Incomplete, illegible, or missing documentation may result in processing delays or denial of the request. Authorization decisions do not guarantee payment; payment is subject to member eligibility.
- Print, type, or write legibly in blue or black ink
- Prescribing physician (PCP or specialist) should generally complete the form
- Incomplete/illegible forms or missing clinical documentation may delay or deny request
- Authorization does not guarantee payment; subject to member eligibility
Required Clinical Documentation
Provide the following clinical documentation with the prior authorization request: a completed prior authorization form with member and provider information, requested drug name, strength, dose, quantity, and day supply; diagnosis and ICD-10 code(s); relevant medication history including trials and failures of generic CNS stimulants (e.g., dextroamphetamine, methylphenidate) or other therapies; and specialty-specific diagnostic test results when applicable (for example, polysomnography results, AHI/RDI, MSLT, MWT, Epworth Sleepiness Scale, CSF hypocretin-1 level).
- Completed prior authorization form with member/provider contact and physician address
- Requested drug, strength, dose, quantity, and day supply
- Diagnosis and ICD-10 code(s)
- Medication history documenting therapeutic failure, intolerance, or contraindication to generic CNS stimulants or other tried therapies
- Relevant diagnostic test results (e.g., polysomnography AHI/RDI, MSLT, MWT, ESS, CSF hypocretin-1)
Submission Completeness — Operational Notes
Follow instructions carefully: submit one form per medication, ensure all fields are completed, and include physician address for notifications. Missing baseline or follow-up objective data (such as sleep study indices or documented stimulant trial failures) can result in denial or request for additional information.
- One form per medication
- Provide physician address for notification
- Ensure baseline and follow-up objective data are included when applicable
- Missing clinical data may prompt denial or additional information requests
Background
This prior‑authorization form supports use of armodafinil (Nuvigil) as a wakefulness‑promoting agent for sleep disorders including narcolepsy, obstructive sleep apnea with residual sleepiness, and shift‑work sleep disorder. For narcolepsy, the form requests baseline objective measures (Epworth Sleepiness Scale, Maintenance of Wakefulness Test, and Multiple Sleep Latency Test results, including mean sleep latency and SOREMP counts), and CSF hypocretin‑1 when deficiency is suspected. For shift‑work sleep disorder, the form requests symptom duration, documentation of reduced total sleep time, and a sleep log or actigraphy record for at least 14 days including both work and free days; it also requires exclusion of other causes. For obstructive sleep apnea, the form asks for diagnostic polysomnography indices (AHI/RDI) and documentation of positive airway pressure or oral appliance use and compliance when applicable.
Definitions and Assessment Tools
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