CurrentUnitedHealthcarePolicy N/A

Prior authorization form — medications for narcolepsy and cataplexy

This document is a prior authorization request form used by prescribers to obtain coverage for drugs to treat narcolepsy and cataplexy; it collects beneficiary, prescriber, drug, and clinical information to determine medical necessity and continuation of therapy.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form — medications for narcolepsy and cataplexy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior authorization form with beneficiary, prescriber, drug, and clinical information including documentation of trial/failure or contraindication to modafinil and armodafinil.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

14clinical questions

11form fields

3therapy durations

Coverage Criteria

Initial therapy criteria

Covered when ALL of the following are met (information required on the form):

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form — medications for narcolepsy and cataplexy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Age: Beneficiary is 18 years of age or olderage >= 18

form question 1

Diagnosis: Beneficiary has a diagnosis of narcolepsy or cataplexy with narcolepsydocumented diagnosis

form questions 9 and 10

Symptom duration: Daytime lapses into sleep or irrepressible need to sleep occurring for at least 3 months>= 3 months

form question 2

Prior therapy: Adequate documented trial and failure of, or contraindication to, modafinil and armodafiniltrial/failure or contraindication documented

form question 11

Safety screening: No unsafe concomitant medications or conditions (concomitant sedative hypnotics, QT-prolonging drugs, H1 antagonists, history of prolonged QTc, end-stage renal disease [eGFR < 15 mL/min/1.73 m2], severe hepatic impairment) that would preclude use without additional monitoringsafety questions answered

form questions 3-8

Continuation therapy criteria

Continuation of therapy covered when ALL of the following are met:

Documented benefit: For narcolepsy: documented reduction in excessive daytime sleepiness from pre-treatment baseline as measured by a validated scaleimprovement documented on validated scale

form question 12

Cataplexy response: For cataplexy: reduced frequency of cataplexy attacks from pretreatment baselinereduction in cataplexy frequency documented

form question 13

Adverse effects: No treatment-restricting adverse effects have occurred (examples include abnormal behavior, abnormal dreams/nightmares, anhedonia, anxiety, bipolar disorder, depression or depressed mood, nausea, QT prolongation, sleep disorder, suicide attempt or suicidal ideation)no treatment-restricting adverse effects

form question 14

Therapy is not considered medically necessary when there is no documentation of an adequate trial and failure of, or contraindication to, modafinil and armodafinil. The form requires the prescriber to answer whether an adequate documented trial and failure of, or contraindication to, these agents exists and to explain contraindications when selected. For continuation requests, the form also requires documentation of a pre-treatment baseline and follow‑up demonstrating clinical benefit (see continuation questions 12–14). Absence of the required prior‑trial documentation or missing baseline/follow‑up outcome data may trigger denial.

Initial Therapy

Initial therapy

Initial approval requires adult age, documented diagnosis and symptom duration, trial/failure or contraindication to modafinil/armodafinil.

Age: Beneficiary is 18 years of age or older

form question 1

Diagnosis: Beneficiary has a diagnosis of narcolepsy or cataplexy with narcolepsy

form questions 9 and 10

Symptom duration: Daytime sleepiness or irrepressible need to sleep occurring for at least 3 months>= 3 months

form question 2

Prior therapy: Documented trial and failure of, or contraindication to, modafinil and armodafinil

form question 11

Continuation of Therapy

Continuation of therapy

Continuation requires documented clinical benefit and absence of treatment-limiting adverse effects.

Narcolepsy benefit: Documented reduction in excessive daytime sleepiness from pre-treatment baseline measured by a validated scale

form question 12

Cataplexy benefit: Reduced frequency of cataplexy attacks from pretreatment baseline

form question 13

Safety monitoring: No treatment-restricting adverse effects present

form question 14

Step	Requirement	Notes
1	Documentation of an adequate documented trial and failure of, or contraindication to, modafinil and armodafinil is required prior to approval.	Form question 11 asks whether an adequate trial and failure of, or contraindication to, modafinil and armodafinil is present; if contraindicated, explanation must be provided on the form.

Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for this medication. Submit the completed prior authorization form with beneficiary, prescriber, drug, and clinical information to support the request.

Include the completed beneficiary demographic fields (last name, first name, beneficiary ID, date of birth, gender).
Include the prescribing provider NPI and requester contact information (name, phone, extension).
Provide drug name, strength, quantity per 30 days, and requested length of therapy.

Documentation Required

Required Clinical Documentation on the Form

The form must include specific clinical documentation to support medical necessity. Missing or incomplete clinical answers are common reasons for delays or denials.

Document age (Is beneficiary ≥18 years?).
Indicate diagnosis: narcolepsy and/or cataplexy.
Answer whether beneficiary has daily periods of irrepressible need to sleep for ≥3 months.
Provide concomitant medication information (sedative-hypnotics, QT-prolonging drugs, H1 antagonists).
Document history of prolonged QTc, end-stage renal disease (eGFR <15), or severe hepatic impairment if applicable.
For continuation requests, document response to therapy using a validated sleepiness scale and change in cataplexy frequency, and report any treatment-restricting adverse effects.

Step Therapy

Step Therapy / Prior Trial Requirement

An adequate documented trial and failure of, or a documented contraindication to, modafinil and armodafinil is required prior to approval. The form includes a specific question confirming prior trial/failure or contraindication; provide details if contraindicated.

Confirm documented trial and failure of modafinil and armodafinil, or state contraindication and explain.
For continuation, include objective improvement from baseline (e.g., Epworth Sleepiness Scale) and reduced cataplexy frequency if applicable.

Denial Risk

Potential Triggers for Denial / Return

Applications lacking required information may be denied or returned for more information. Provide complete, legible entries and prescriber signature.

Potential triggers for denial include missing beneficiary age, missing or unclear diagnosis (narcolepsy or cataplexy), or absence of documented trial/failure or contraindication to modafinil/armodafinil.
Incomplete drug information (name, strength, quantity, length of therapy), missing prescriber NPI or contact information, and absent prescriber signature (required) may result in denial.
Failure to document response to therapy for continuation requests or to report relevant safety risks (QTc prolongation, renal/hepatic impairment, concomitant QT‑prolonging medications) can also trigger denial.

Coding and Clinical Thresholds

inv-05: End-stage renal disease (eGFR) — < 15 mL/min/1.73 m2.

End-stage renal disease (eGFR)Defined on the form as eGFR < 15 mL/min/1.73 m2

Form questionQuestion 7 asks: 'Does the beneficiary have end-stage renal disease (estimated glomerular filtration rate [eGFR] < 15 mL/min/1.73 m2)?'

ImplicationPresence of end-stage renal disease is queried during safety screening and may affect eligibility or require monitoring

inv-06: Duration of symptoms for excessive daytime sleepiness — at least 3 months.

Duration requiredDaytime lapses into sleep or irrepressible need to sleep occurring for at least 3 months

Form questionQuestion 2 asks whether symptoms have occurred for at least three (3) months

Use in continuity assessmentSymptom duration is part of initial therapy criteria to establish chronic excessive daytime sleepiness

Definitions

inv-12: Validated sleepiness scale — Examples listed on the form include Epworth Sleepiness Scale, Stanford Sleepiness Scale, Karolinska Sleepiness Scale, etc.

Examples listed on formEpworth Sleepiness Scale, Stanford Sleepiness Scale, Karolinska Sleepiness Scale, Cleveland Adolescent Sleepiness Questionnaire, or a Visual Analog Scale

PurposeUsed to measure reduction in excessive daytime sleepiness from pre-treatment baseline for continuation of therapy (Question 12)

DocumentationForm requires 'documented reduction... as measured by a validated scale' to support continuation approval

inv-13: End-stage renal disease (as used in form) — defined on the form as eGFR < 15 mL/min/1.73 m2.

Form definitionEnd-stage renal disease is defined on the form as eGFR < 15 mL/min/1.73 m2

Screening questionQuestion 7 asks specifically whether the beneficiary has end-stage renal disease (eGFR < 15 mL/min/1.73 m2)

RelevanceQueried as part of safety screening that may preclude use or require additional monitoring

Background

This prior authorization form is intended for medications used to treat narcolepsy and cataplexy. It collects clinical safety screening questions for risks that influence appropriateness of therapy, including concomitant use of sedative hypnotic agents (e.g., zolpidem, eszopiclone, zaleplon, benzodiazepines, barbiturates), use of drugs that prolong the QT interval (examples listed on the form), concomitant H1 receptor antagonists, history of prolonged QTc, end-stage renal disease (eGFR < 15 mL/min/1.73 m2), and severe hepatic impairment. For continuation, the form captures outcome measures including validated sleepiness scales and change in cataplexy frequency, and it asks about treatment‑restricting adverse effects.

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