CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Provigil Pa With Limit 178 C 2814 C P01 2025

Prior authorization and quantity-limit policy for Provigil (modafinil) covering FDA-approved indications (narcolepsy, OSA-related excessive sleepiness, shift work disorder) and selected compendial uses (idiopathic hypersomnia, multiple sclerosis-related fatigue). Defines clinical criteria for authorization, quantity limits, and duration of approval.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyProvigil Pa With Limit 178 C 2814 C P01 2025

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionAuthorization requires documentation meeting the specific indication criteria and, for many indications, prescription by or consultation with a sleep specialist.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes noted in this update.

4Covered Indications (with criteria)

12Duration of Approval (months)

60/25d;180/75dQuantity Limits

Coverage Summary

Scope: Prior authorization and quantity-limit policy for Provigil (modafinil) covering FDA-approved indications — narcolepsy, obstructive sleep apnea (OSA)-related excessive sleepiness, and shift work disorder (SWD) — and selected compendial uses including idiopathic hypersomnia and multiple sclerosis-related fatigue. Coverage stance: covered_with_criteria. Status: CURRENT.

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Initial Therapy Criteria

Idiopathic Hypersomnia - Initial Authorization

Authorization may be granted when the requested drug is being prescribed for idiopathic hypersomnia when ALL of the following criteria are met:

ALL of the following

The requested drug is being prescribed by, or in consultation with, a sleep specialist.
The patient has experienced the presence of daytime lapses into sleep or daily irrepressible periods of need to sleep for at least 3 months.>= 3 months
Insufficient sleep syndrome has been ruled out such as by lack of improvement of sleepiness after an adequate trial of increased nocturnal time in bed, preferably confirmed by at least a week of sleep log with wrist actigraphy.>= 7 days (sleep log + wrist actigraphy preferred)
A multiple sleep latency test (MSLT) documented fewer than two sleep onset rapid eye movement periods (SOREMPs) or no SOREMPs if the rapid eye movement (REM) latency on the preceding polysomnogram was less than or equal to 15 minutes.<2 SOREMPs or none if REM latency on preceding PSG <= 15 minutes
ONE of
- Sleep lab evaluation showed mean sleep latency on MSLT of less than or equal to 8 minutes.<= 8 minutes
- Sleep lab evaluation showed total 24-hour sleep time of greater than or equal to 660 minutes on 24-hour polysomnographic monitoring after correcting any chronic sleep deprivation.>= 660 minutes
- Sleep lab evaluation showed total 24-hour sleep time of greater than or equal to 660 minutes by wrist actigraphy in association with a sleep log and averaged over at least 7 days of unrestricted sleep.>= 660 minutes, averaged over >= 7 days
The patient does NOT have cataplexy.
Hypersomnolence or MSLT results are not better explained by ANY of the following: another sleep disorder, other medical or psychiatric disorder, use of drugs or medications.

Multiple Sclerosis-Related Fatigue - Initial Authorization

Authorization may be granted when the requested drug is being prescribed for multiple sclerosis-related fatigue.

ALL of the following

Requested drug is being prescribed for multiple sclerosis-related fatigue.

Provider Actions & Requirements

Prior Authorization

Prior authorization required for Provigil

Prior authorization is required for Provigil. Authorization requires documentation that meets the specific indication criteria in the policy, and for many indications the drug must be prescribed by, or in consultation with, a sleep specialist.

Documentation Required

Sleep study documentation required for narcolepsy and OSA

Narcolepsy requires a diagnosis confirmed by a sleep study. For obstructive sleep apnea (OSA), the diagnosis must be confirmed by polysomnography or a home sleep apnea test (HSAT) performed with a technically adequate device.

Documentation Required

Sleep logs/actigraphy requirements

Sleep log and actigraphy documentation is required for certain indications: idiopathic hypersomnia requires confirmation that insufficient sleep syndrome was ruled out, preferably confirmed by at least one week of sleep log with wrist actigraphy; shift work disorder (SWD) requires a sleep log and actigraphy monitoring completed for at least 14 days showing a disrupted sleep–wake pattern.

Documentation Required

CPAP/BIPAP treatment documentation for OSA

For OSA, document at least one month of CPAP or BIPAP use prior to initiating Provigil and that the patient will continue CPAP or BIPAP after the drug is started.

Billing Rule

Quantity limits apply

Quantity limits apply: 60 tablets per 25 days (30-day fill equivalent) or 180 tablets per 75 days (90-day fill equivalent).

Step Therapy

Specialist involvement requirement

Many indications require that the drug be prescribed by, or in consultation with, a sleep specialist as a condition for authorization.

Background

Background: Provigil (modafinil) is FDA-approved to improve wakefulness in adults with excessive sleepiness associated with narcolepsy, obstructive sleep apnea (OSA), and shift work disorder (SWD). Compendial uses referenced in the policy include treatment of idiopathic hypersomnia and fatigue related to multiple sclerosis.

Glossary: SOREMP — Sleep onset rapid eye movement period.

MSLT — Multiple Sleep Latency Test.

CPAP/BIPAP — Continuous/Bilevel positive airway pressure.

HSAT — Home sleep apnea test.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyProvigil Pa With Limit 178 C 2814 C P01 2025

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionAuthorization requires documentation meeting the specific indication criteria and, for many indications, prescription by or consultation with a sleep specialist.

SourceLink

On This Page

OpenPayer

Provigil Pa With Limit 178 C 2814 C P01 2025

Coverage Summary

Initial Therapy Criteria

Continuation / Renewal Criteria

Provider Actions & Requirements

Applicable Codes

Clinical Evidence & References

Background

Revision History