CurrentHighmark Blueshield NenyPolicy N/A

Modafinil (Provigil) prior authorization form for sleep disorders

Form and criteria for prior authorization / reauthorization of modafinil (Provigil) for conditions including obstructive sleep apnea, narcolepsy, idiopathic hypersomnia, shift-work sleep disorder, and multiple sclerosis–related fatigue for Highmark BlueShield regions. Affects prescribing providers requesting coverage for modafinil.

Policy Summary

PayerHighmark Blueshield Neny

PolicyModafinil (Provigil) prior authorization form for sleep disorders

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed prior authorization form with supporting clinical documentation and required provider information via fax to 1-866-240-8123 or by mail.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multiple indicationsindications listed on form

14 daysshift-work monitoring

660 min (11h)idiopathic hypersomnia threshold

1-866-240-8123submission fax

Coverage Criteria by Indication

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Obstructive Sleep Apnea — coverage criteria

Covered when clinical documentation for obstructive sleep apnea supports residual excessive sleepiness despite primary therapy and diagnostic severity is provided.

OSA approval criteria: 1) Member currently receiving and compliant with positive airway pressure (PAP) OR using a custom titratable oral appliance (documented).; 2) Member has experienced therapeutic failure, intolerance, or contraindication to PAP OR documents residual excessive sleepiness despite PAP.; 3) Provide diagnostic polysomnography Apnea-Hypopnea Index (AHI) value.; 4) Document presence of relevant symptoms (e.g., daytime sleepiness, cognitive dysfunction, cardiovascular comorbidities, unrefreshing sleep, fatigue, loud snoring).

From OSA section

Narcolepsy — coverage criteria

Covered when narcolepsy diagnostic testing and symptom measures are documented.

Narcolepsy approval criteria: 1) Provide baseline Epworth Sleepiness Scale (ESS) and Maintenance of Wakefulness Test (MWT) where available.; 2) Provide MSLT results: mean sleep latency (minutes) and number of SOREMPs.; 3) Provide PSG SOREMPs if available.; 4) If hypocretin-1 deficiency suspected or proven, provide CSF hypocretin-1 level and laboratory reference range.

From Narcolepsy section

Idiopathic Hypersomnia — coverage criteria

Covered when idiopathic hypersomnia diagnostic criteria are documented.

Idiopathic hypersomnia approval criteria: 1) Provide baseline ESS and MWT.; 2) Provide MSLT mean sleep latency.; 3) Provide PSG number of SOREMPs.; 4) State presence or absence of cataplexy.; 5) Provide polysomnography demonstrating total 24-hour sleep time >= 660 minutes (11 hours) OR wrist actigraphy demonstrating >= 660 minutes per 24 hours averaged across >= 7 days of monitoring.>= 660 minutes

From Idiopathic Hypersomnia section

Shift-work Sleep Disorder — coverage criteria

Covered when shift-work sleep disorder is documented.

Shift-work sleep disorder approval criteria: 1) Excessive sleepiness or insomnia temporally associated with a recurring work schedule that overlaps usual sleep time.; 2) Symptoms accompanied by reduced total sleep time.; 3) Symptoms present for >= 3 months.; 4) Provide sleep log or actigraphy monitoring for >= 14 days including work and free days.; 5) Exclude other primary sleep disorders, medical/neurologic/mental disorders, medication use, or substance use as the cause.>= 3 months; >=14 days monitoring

From Shift-work section

Multiple Sclerosis — coverage criteria

Covered when multiple sclerosis–related fatigue is documented.

MS fatigue approval criteria: 1) Documentation that member has multiple sclerosis and is experiencing significant fatigue.

From Multiple Sclerosis section

Reauthorization and Quantity — coverage criteria

Reauthorization and quantity increase considerations.

Reauthorization criteria: 1) Indicate if request is for reauthorization.; 2) Document symptomatic improvement on therapy (e.g., fatigue, daytime sleepiness) and objective improvement on ESS or MWT compared to baseline.; 3) For requests for >1 tablet (200 mg/day), document inadequate control on 200 mg daily (including once-daily morning dosing) before approving higher dose/quantity.

From Reauthorization and Quantity sections

Approvals are contingent on condition-specific diagnostic data and documentation of trials or compliance with indicated primary therapies. For example, requests for obstructive sleep apnea require documentation of current use and compliance with positive airway pressure (PAP) or documented use of a custom titratable oral appliance and provision of diagnostic polysomnography results including the Apnea-Hypopnea Index (AHI). Requests for shift-work sleep disorder must include symptoms present for at least 3 months and sleep log or actigraphy monitoring for at least 14 days. For idiopathic hypersomnia and narcolepsy, provide objective testing such as MSLT results (mean sleep latency and SOREMPs), PSG data, and baseline sleepiness measures (ESS, MWT) as applicable. Absence of these condition-specific tests or lack of documented trial/compliance with primary therapies (e.g., PAP for OSA) will make approval unlikely.

The form requires justification when quantity or dosing exceeds the standard single-tablet regimen. Specifically, requests asking for more than one 200 mg tablet per day must document that the member’s daytime sleepiness was inadequately controlled on 200 mg daily (including inadequate control on 200 mg once daily in the morning) before additional tablets or higher total daily dosing will be considered.

What the Provider Must Submit

Prior Authorization

Prior Authorization Required

Prior authorization is required. Submit a completed form and all supporting clinical documentation (diagnostic test results, medication trials, baseline assessments) by fax to 1-866-240-8123 or by mail to: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222. The prescribing physician (PCP or Specialist) should complete the form; include physician signature and date.

Fax: 1-866-240-8123
Mail: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222
Include completed form + supporting clinical documentation

Step Therapy

Trials of Alternatives Expected

Trials of alternatives are expected. Document therapeutic failure, intolerance, or contraindication to a generic CNS stimulant (for example, dextroamphetamine, methylphenidate). For obstructive sleep apnea (OSA) indications, document failure/intolerance/contraindication to positive airway pressure (PAP) therapy and, when applicable, trial of a custom titratable oral appliance.

Document trial and reason for failure/intolerance/contraindication to generic CNS stimulants
For OSA: document PAP use and compliance and trial/failure/intolerance if applicable
Document trials of other relevant medications tried and failed

Documentation Required

Required Clinical Documentation

Provide condition‑specific baseline and diagnostic data as applicable: Epworth Sleepiness Scale (ESS), Maintenance of Wakefulness Test (MWT), Multiple Sleep Latency Test (MSLT) results (mean sleep latency, number of SOREMPs), diagnostic polysomnography data (AHI, SOREMPs, total 24‑hour sleep time), and actigraphy or sleep log when required. For narcolepsy with hypocretin deficiency, include CSF hypocretin‑1 level and lab reference range. For shift‑work disorder include 14+ day sleep log or actigraphy.

ESS and MWT baseline data where requested
MSLT: mean sleep latency and number of SOREMPs
Polysomnography: AHI, SOREMPs, total 24‑hour sleep time if applicable
Wrist actigraphy or sleep log data when required (≥7 days or ≥14 days per condition)
CSF hypocretin‑1 level and reference range if available

Documentation Required

Administrative Submission Requirements

Include provider administrative information on the submission: physician name, NPI, phone, fax, full address (including suite/building, city, state, zip), and the prescribing physician's signature and date. Certify that information is true, accurate, and that services are medically necessary.

Physician name, NPI, phone, fax, address (suite/building, city, state, zip)
Prescribing physician signature and date
Statement certifying accuracy and medical necessity

Billing Rule

Quantity Justification Required

Quantity justification is required for requests exceeding standard dosing or more than one tablet per day (e.g., >1 tablet per day of modafinil 200 mg). If requesting higher than standard dosing, provide documentation that daytime sleepiness was inadequately controlled on standard dosing (including once‑daily morning dosing) and rationale supporting the increased quantity.

Requests >1 tablet/day (e.g., modafinil 200 mg) require clinical justification
Document inadequate control on standard dosing (including once‑daily morning dosing) before approving higher quantities

Denial Risk

Condition‑Specific Documentation Required

Condition‑specific fields on the form must be fully completed. Missing documentation of diagnostic criteria, required baseline/diagnostic test results, or prior trials/compliance (e.g., PAP compliance for OSA, actigraphy for idiopathic hypersomnia or shift‑work disorder) may lead to denial for insufficient information.

Ensure all condition‑specific sections are completed (Narcolepsy, OSA, Idiopathic Hypersomnia, Shift‑Work Disorder, Multiple Sclerosis)
Include trials/compliance evidence (PAP, oral appliance, actigraphy, sleep logs) as applicable
Incomplete or missing required data may result in denial

OpenPayer

Modafinil (Provigil) prior authorization form for sleep disorders

Coverage Criteria by Indication

Medication, Measures, and Thresholds

What the Provider Must Submit

Key Definitions and Thresholds

Background