CurrentHighmark Blueshield NenyPolicy N/A

Armodafinil (Nuvigil) — Prior Authorization Coverage Criteria for Sleep Disorders

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.

Policy Summary

PayerHighmark Blueshield Neny

PolicyArmodafinil (Nuvigil) — Prior Authorization Coverage Criteria for Sleep Disorders

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with required clinical documentation (diagnostic test results, prior medication history, and sleep logs/actigraphy) and fax or mail a separate form for each medication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3primary indications

≥14dmonitoring duration

ESS/MWT/MSLTbaseline tests

PAP compliancePAP requirement

Coverage Criteria for Armodafinil (Nuvigil)

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Obstructive Sleep Apnea (OSA) - coverage criteria

Covered when documentation demonstrates appropriate prior therapies and diagnostic data for OSA-related residual sleepiness:

OSA coverage prerequisites: Member is currently receiving and compliant with positive airway pressure (PAP) OR using and compliant with a custom, titratable oral appliance; and member has documentation of diagnostic polysomnography with AHI or RDI reported; and provider documents therapeutic failure/intolerance/contraindication to PAP if not compliant.AHI/RDI provided

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:

Narcolepsy coverage prerequisites: Provide baseline ESS and MWT results; provide MSLT results including mean sleep latency and number of SOREMPs; if hypocretin-1 deficiency suspected, provide CSF hypocretin-1 level and laboratory reference range; documentation must support daytime sleepiness and diagnostic testing consistent with narcolepsy.MSLT mean latency and SOREMP counts provided

Form asks for evidence of symptom improvement if requesting reauthorization.

Shift-Work Sleep Disorder - coverage criteria

Covered when documentation supports shift-work sleep disorder:

Shift-work sleep disorder criteria: Excessive sleepiness or insomnia linked to a recurring work schedule that overlaps usual sleep time; symptoms present for at least 3 months; symptoms accompanied by a reduction of total sleep time; sleep log or actigraphy monitoring for at least 14 days including work and free days; and exclusion of other sleep, medical, psychiatric, medication, or substance causes.≥14 days monitoring

Form requests documentation of symptom duration and exclusion of other causes.

Prior therapy requirement

Prior medication failure requirement (where applicable):

Prior stimulant trial: Document therapeutic failure, contraindication, or intolerance to a generic CNS stimulant (for example, dextroamphetamine, methylphenidate) or list other medications tried and failed.document prior failures

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.

Provider Submission and Documentation Requirements

Prior Authorization

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

Denial Risk

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

Documentation Required

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)

Note

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

inv-14: Epworth Sleepiness Scale (ESS) — baseline ESS requested for narcolepsy assessment

Requested measureBaseline Epworth Sleepiness Scale (ESS) score

UseQuantifies excessive daytime sleepiness to support narcolepsy diagnosis

Form entryProvider must record ESS numeric score on the prior authorization form

inv-15: Maintenance of Wakefulness Test (MWT) — objective test requested for narcolepsy assessment

Requested testBaseline Maintenance of Wakefulness Test (MWT) results

PurposeObjective assessment of ability to remain awake to support narcolepsy evaluation

Form entryProvider must provide MWT results on the prior authorization form

inv-16: Multiple Sleep Latency Test (MSLT) — objective nap study requested for narcolepsy assessment

Requested studyMultiple Sleep Latency Test (MSLT) results including mean sleep latency and number of SOREMPs

ParametersProvide mean sleep latency (minutes) and number of sleep-onset REM periods (SOREMPs)

Related PSG dataAlso provide number of SOREMPs observed on diagnostic polysomnography if available

inv-17: Apnea/Hypopnea Index (AHI) / Respiratory Disturbance Index (RDI) — requested for OSA-related sleepiness

Requested indicesApnea/hypopnea index (AHI) in events/hour

Alternate metricRespiratory disturbance index (RDI) in events/hour

SourceValues requested from the member's diagnostic polysomnography as entered on the form

OpenPayer

Armodafinil (Nuvigil) — Prior Authorization Coverage Criteria for Sleep Disorders

Coverage Criteria for Armodafinil (Nuvigil)

Coding and Monitoring Requirements

Provider Submission and Documentation Requirements

Background

Definitions and Assessment Tools