CurrentHighmark Blueshield NenyPolicy N/A

Nuvigil (Armodafinil) prior authorization/coverage form

This document is a payer prior authorization/coverage form for Nuvigil (armodafinil) used in sleep medicine indications (narcolepsy, obstructive sleep apnea residual sleepiness, shift-work sleep disorder). It captures required clinical information and documentation to support an authorization request.

Policy Summary

PayerHighmark Blueshield Neny

PolicyNuvigil (Armodafinil) prior authorization/coverage form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must complete and submit a separate, legible prior authorization form for each medication request and include all required clinical documentation and signatures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3primary clinical indications covered on form (narcolepsy, OSA, shift-work sleep disorder)

>=1clinical data elements required per indication (e.g., ESS, MWT, AHI, MSLT)

1fax number for submission

Authorization and Clinical Documentation Requirements

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ALL of the following

Complete separate form for each medication request
Provide member identifying information (ID, name, DOB, address)
Provide provider information including NPI, address, signature and date
List requested drug, strength, quantity, directions, and ICD-10 diagnosis code(s)
Provide medication history including failure/intolerance/contraindication to a generic CNS stimulant (e.g., dextroamphetamine, methylphenidate) and other tried medications