CurrentUnitedHealthcarePolicy N/A

NC Pharmacy Prior Approval Request for Antinarcolepsy Agents (Provigil, Nuvigil, Armodafinil, Modafinil)

A beneficiary/prescriber prior authorization (PA) form used by UnitedHealthcare (North Carolina) for requests for antinarcolepsy medications (Provigil, Nuvigil, Armodafinil, Modafinil). It collects beneficiary, prescriber, drug, and clinical information to support initial or continuation PA decisions.

Policy Summary

PayerUnitedHealthcare

PolicyNC Pharmacy Prior Approval Request for Antinarcolepsy Agents (Provigil, Nuvigil, Armodafinil, Modafinil)

Policy CodePolicy N/A

Change TypeInformational form (no material changes)

Effective Date

Next Review Date

Key ActionProviders must complete the PA form including beneficiary, prescriber, drug, and clinical fields (document prior trials of preferred agents if requesting a non-preferred drug) and include the prescriber signature for PA processing.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes - form is informational and no policy changes were reported.

4Drugs referenced

7Key fields to complete

Policy overview

This administrative form is a UnitedHealthcare (North Carolina) pharmacy prior authorization (PA) request used to collect beneficiary, prescriber, drug, and clinical information to support coverage decisions for wakefulness‑promoting agents. It specifically references Provigil, Nuvigil, Armodafinil, and Modafinil.

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Coverage stance & intended use

Coverage stance: informational. This document is an administrative PA form used to collect information needed to adjudicate pharmacy prior authorization requests — it is not itself an explicit clinical coverage policy or a definitive list of medically necessary criteria.

While many form fields map to common clinical requirements (for example, indication, prior trials of preferred agents, and evidence of benefit for continuation), the form’s role is to document information to support coverage decisions rather than to define the medical necessity standards themselves.

What providers must do

Documentation Required

Complete PA form including clinical justifications

Providers must complete the PA form capturing beneficiary, prescriber, drug, and clinical information, and include clinical justifications such as prior trials when requesting non-preferred agents and evidence of benefit for continuation; prescriber signature is mandatory.

Beneficiary: last name, first name, beneficiary ID, date of birth, gender
Prescriber: NPI, requester contact name, phone, ext
Drug: name, strength, quantity per 30 days, length of therapy
Indication/diagnosis (e.g., narcolepsy, shift work sleep disorder, OSA)
Prior trials of Provigil and Nuvigil required if requesting a non-preferred medication
For continuation: evidence of reduced daytime sleepiness on a validated scale (e.g., Epworth, Cleveland Adolescent Sleepiness Questionnaire, Visual Analog Scale)
Prescriber signature (mandatory)

Prior Authorization

Prior authorization required

This form is the North Carolina pharmacy prior approval request for the named antinarcolepsy agents and must be submitted to the Pharmacy PA Call Center.

Billing Rule

Contact for PA submission

Submit the completed PA form to the Pharmacy PA Call Center at the number below; prescriber signature on the form is required for PA processing.

1-855-258-1593

Who and when this form applies

Scope and applicability

Geographic / Organizational scopeUnitedHealthcare - North Carolina (NC Pharmacy Prior Approval)

Applicable drugsProvigil, Nuvigil, Armodafinil, Modafinil

Use cases coveredInitial authorization and reauthorization (continuation) for narcolepsy; excessive sleepiness associated with shift work sleep disorder; other listed diagnoses including obstructive sleep apnea/hypopnea syndrome

Form collectsBeneficiary, prescriber, drug, and clinical information to support PA decisions (e.g., prior trials of preferred agents, length of therapy, dosage)

Continuation requirementsFor continuation, documentation of reduction in excessive daytime sleepiness from pre-treatment baseline using validated scale (e.g., Epworth, Cleveland Adolescent Sleepiness Questionnaire, Visual Analog Scale)

Prior trial requirement for non-preferred medsIf prescribed a non-preferred medication, must document trial and failure of Provigil and Nuvigil or provide clinical reason why preferred agents cannot be used

Purpose and context

Background: The form’s intent is to collect the information necessary to adjudicate pharmacy prior authorization requests for antinarcolepsy/wakefulness‑promoting agents, including beneficiary and prescriber details, drug-specific information (name, strength, quantity per 30 days, and length of therapy), and clinical indication(s).

It requires documentation of prior medication trials when a non‑preferred medication is requested — specifically whether the beneficiary has tried and failed Provigil and Nuvigil and, if not, a clinical reason why preferred medications cannot be used — and for continuation requests it requires evidence of clinical benefit such as reduction in excessive daytime sleepiness on a validated scale. Prescriber signature is mandatory for PA processing.