CurrentHighmark Blueshield NenyPolicy N/A

Prior Authorization Request Form for Armodafinil/Nuvigil

This is a medication prior authorization (PA) request form used by Highmark BlueShield entities to collect member, provider, medication, diagnosis, and clinical history information to support coverage decisions for armodafinil (Nuvigil) and generic armodafinil for sleep disorders (narcolepsy, obstructive sleep apnea, shift-work sleep disorder). It does not itself state coverage criteria or reimbursement rules but is an administrative tool required to request authorization.

Policy Summary

PayerHighmark Blueshield Neny

PolicyPrior Authorization Request Form for Armodafinil/Nuvigil

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a completed prior authorization form with required clinical documentation and fax to 1-866-240-8123 or mail to 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222.

POLICY UPDATE CHANGES

No material clinical/coverage changes — form is administrative and unchanged.

3Primary Indications on form

4Strength options

2Day supply options

Policy / Form Summary

This document is an administrative prior authorization (PA) request form used to collect clinical and administrative information needed by Highmark entities to evaluate requests for armodafinil (Nuvigil) or generic armodafinil for excessive daytime sleepiness related to narcolepsy, obstructive sleep apnea (OSA), or shift-work sleep disorder. It gathers member, provider, medication (including strength and day supply), diagnosis, and clinical history details to support a PA decision.

Clinical Information Requested (by indication)

Clinical information requested by indication

Document collects required clinical details depending on the indication; responses guide prior authorization decision-making.

Indication-specific sections (complete applicable section)

General medication request details: requested drug (Brand Nuvigil or Generic Armodafinil), strength (50 mg, 150 mg, 200 mg, 250 mg), requested quantity, requested day supply (30 or 90 days), directions, diagnosis and ICD-10 code(s).
Medication history: Has the member experienced therapeutic failure, contraindication, or intolerance to a generic CNS stimulant (for example, dextroamphetamine, methylphenidate)?
Yes/No and space to list other medications tried and failed.
Obstructive Sleep Apnea (OSA): Obstructive Sleep Apnea (if used for OSA): Is the member currently receiving and compliant with positive airway pressure (PAP)? Has the member experienced therapeutic failure, intolerance, or contraindication to PAP? Is the member currently using and compliant with a custom, titratable oral appliance? Select all applicable symptoms from checklist and provide diagnostic polysomnography results (AHI and RDI).
Symptoms checklist includes coronary artery disease; unrefreshing sleep; mood disorder; insomnia; congestive heart failure; cognitive dysfunction; atrial fibrillation; fatigue; type 2 diabetes mellitus; daytime sleepiness; hypertension; stroke; unintentional sleep episodes during wakefulness; waking up holding breath/gasping/choking; bed partner describes loud snoring or breathing interruptions.
OSA — Polysomnography values: Provide Apnea/Hypopnea Index (AHI) in events/hour and Respiratory Disturbance Index (RDI) in events/hour from diagnostic polysomnography.AHI: numeric (events/hour); RDI: numeric (events/hour)
Narcolepsy (if used for narcolepsy): Provide baseline Excessive Daytime Sleepiness via Epworth Sleepiness Scale (ESS) and baseline data via Maintenance of Wakefulness Test (MWT). Provide MSLT results: mean sleep latency (minutes) and number of SOREMPs; provide polysomnography number of SOREMPs. If hypocretin-1 deficiency, provide cerebrospinal fluid hypocretin-1 level and laboratory reference range.ESS: numeric; MWT: numeric; MSLT mean sleep latency: numeric (minutes); Number of SOREMPs: numeric; CSF hypocretin-1: numeric (pg/mL)
Shift-Work Sleep Disorder (SWSD): Shift-Work Sleep Disorder (if used for SWSD): Confirm excessive sleepiness or insomnia temporarily associated with a recurring work schedule overlapping usual sleep time; indicate whether symptoms are accompanied by reduction of total sleep time; confirm symptoms duration at least 3 months; confirm sleep log or actigraphy monitoring for at least 14 days including work and free days; determine whether sleep disturbance is due to another sleep, medical, neurological, mental, medication, or substance use disorder.Duration: >= 3 months; Sleep log/actigraphy: >= 14 days
Reauthorization: Is the member currently on therapy with the requested medication? If yes, indicate whether symptoms have improved while on therapy (improvement in fatigue or daytime sleepiness) and whether there is documented improvement on ESS or MWT compared to baseline.

Administrative notes for medication fields: Include medication strength, requested quantity, and day supply options (30 or 90 days) in the request form.

Use listed strength options: 50 mg, 150 mg, 200 mg, 250 mg; Day supply options: 30 or 90 days.

What Providers Must Do

Prior Authorization

Submit separate form per medication and clinical documentation

Submit a completed prior authorization form for each medication, including required clinical documentation; fax to 1-866-240-8123 or mail to 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222.

Documentation Required

Complete indication-specific clinical data fields

Provide medication history, diagnostic test results (AHI, RDI, ESS, MWT, MSLT, CSF hypocretin if applicable), symptom checklists and adherence to PAP or oral appliance when applicable; attach supporting clinical records.

Documentation Required

Prescribing physician signature and contact details required

Provide physician name, NPI, address, signature and date certifying accuracy.

Definitions

PAPPositive airway pressure therapy for obstructive sleep apnea.

AHIApnea/hypopnea index in events per hour from polysomnography.

RDIRespiratory Disturbance Index from polysomnography.

ESSEpworth Sleepiness Scale measuring excessive daytime sleepiness.

MWTMaintenance of Wakefulness Test.

MSLTMultiple Sleep Latency Test; includes mean sleep latency and SOREMP count.

The form collects indication-specific clinical information such as medication failure history (e.g., prior trial and intolerance/contraindication to a generic CNS stimulant or PAP), objective diagnostic test results (AHI, RDI, ESS, MWT, MSLT, SOREMPs, CSF hypocretin-1 when applicable), and documentation of adherence to primary therapy (for example, compliance with positive airway pressure or a custom oral appliance for OSA).

It also requests medication details (requested drug: Brand Nuvigil or Generic Armodafinil; strengths: 50 mg, 150 mg, 200 mg, 250 mg; requested day supply: 30 or 90 days), symptom checklists, and reauthorization information about clinical improvement while on therapy. The completed form and supporting records must be faxed to 1-866-240-8123 or mailed to the address on the form.

OpenPayer

Prior Authorization Request Form for Armodafinil/Nuvigil

Policy / Form Summary

Clinical Information Requested (by indication)

What Providers Must Do

Definitions

Diagnostic Tests & Thresholds

Document Revision History