Provigil (modafinil) — Highmark
Fatigue Associated with Multiple Sclerosis
Preferred products
- generic modafinil
Initial criteria
- diagnosis of multiple sclerosis (ICD-10: G35) with associated fatigue
- IF request is for brand Provigil: therapeutic failure or intolerance to generic modafinil
Reauthorization criteria
- member’s symptoms of fatigue have improved