Prior Authorization Criteria — Modafinil (Provigil) for Sleep Disorders
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This form governs prior authorization requirements for Provigil (modafinil) and generic modafinil for members of Highmark Pennsylvania when used to treat sleep-related disorders (e.g., obstructive sleep apnea, narcolepsy, idiopathic hypersomnia, shift-work sleep disorder, MS-related fatigue). It affects prescribing providers who must submit clinical information to obtain authorization.
No material clinical or coverage changes in this revision.
Coverage Criteria for Modafinil (Provigil)
Indication-specific coverage criteria
Covered when ALL of the following supporting documentation is provided for the specific indication
See form completion and submission instructions.
Provide prior medication history as requested on the form.
Include PSG AHI/RDI and PAP/oral appliance use per form.
Provide ESS, MWT, MSLT, PSG, and CSF hypocretin-1 data as applicable.
PSG or actigraphy demonstrating >=660 minutes (11 hours) total sleep time per 24 hours averaged per monitoring requirements.
Provide 14-day sleep log or actigraphy including work and free days and documentation excluding other causes.
Indicate presence of significant MS-related fatigue on the form.
Reauthorization criteria
Covered for reauthorization when ALL of the following are met
Confirm current therapy status on the reauthorization section of the form.
Provide clinical notes or symptom assessments indicating improvement.
Provide comparative ESS or MWT results as recorded on the reauthorization portion of the form.
For a diagnosis of shift-work sleep disorder, the form requires exclusion of other causes of sleep disturbance. Specifically, the provider must confirm that the member’s sleep disturbance is not explained by another current sleep disorder, a medical or neurological disorder, a mental disorder, medication use, or a substance use disorder. This exclusion is necessary to ensure that symptoms are attributable to the work schedule and to support medical necessity for modafinil in this indication.
Completion of the prior authorization form documents a provider’s request for coverage but does not ensure payment. Authorization does not guarantee payment; coverage and payment remain subject to the member’s eligibility and benefits at the time the claim is submitted. Providers must submit a complete, legible form with required clinical documentation and accurate member information via the fax or mailing instructions on the form to initiate review.
Requested Medication and Diagnostic Codes
| Provigil / Modafinil | Requested drug — Brand Provigil or Generic Modafinil, strengths 100mg or 200mg |
| ICD-10 | Diagnosis and/or ICD-10 code(s) (provider to supply) |
What the Prescribing Provider Must Submit
Prior authorization required — submit form with clinical documentation
Prior authorization is required. Submit the completed prior authorization form with all required clinical documentation and medication details; fax to 1-866-240-8123 or mail to 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222 per the form instructions.
Step therapy / quantity justification — document prior stimulant failure or inadequate control
Document therapeutic failure, intolerance, or contraindication to a generic CNS stimulant (for example dextroamphetamine or methylphenidate) when applicable; if requesting more than one 200 mg tablet per day, indicate whether daytime sleepiness was inadequately controlled on Provigil (Modafinil) 200 mg once daily.
Submit completed, legible PA form with member/provider and medication details
Submit a completed, legible prior authorization form that includes member and provider information, the requested drug (brand Provigil or generic modafinil), strength, dose, quantity/day supply, and diagnosis with ICD-10 code(s).
Include indication-specific objective data (ESS, MWT, MSLT, PSG/actigraphy)
Include indication‑specific objective data with the request: for narcolepsy and idiopathic hypersomnia provide baseline ESS and MWT and MSLT results (mean sleep latency and number of SOREMPs); include PSG SOREMPs or CSF hypocretin-1 when applicable; for idiopathic hypersomnia provide 24‑hour total sleep time data (≥660 minutes) from PSG or actigraphy.
Provide prior medication history showing failure/intolerance to generic stimulants
Provide prior medication history documenting therapeutic failure, intolerance, or contraindication to a generic CNS stimulant; list other medications the member has tried and failed.
Authorization does not guarantee payment — check member eligibility
Payment is subject to member eligibility; authorization does not guarantee payment.
Background
Modafinil (Provigil or generic modafinil) is used to treat excessive daytime sleepiness across several clinical contexts. Common indications include sleepiness associated with obstructive sleep apnea, narcolepsy, idiopathic hypersomnia, shift-work sleep disorder, and fatigue related to multiple sclerosis. The prior authorization form is structured to collect objective sleep study data, symptom scales, and medication history to document diagnosis, baseline severity, and treatment response when modafinil is requested.
Key Definitions
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