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Provigil (modafinil) — Highmark

Idiopathic Hypersomnia (IH)

Initial criteria

  • age ≥ 18 years
  • diagnosis of idiopathic hypersomnia (ICD-10: G47.11 or G47.12)
  • member does not have a diagnosis of cataplexy
  • prescriber provides polysomnography and/or MSLT substantiating < 2 SOREMPs
  • prescriber provides ONE of the following: (a) MSLT demonstrating mean sleep latency ≤ 8 minutes; OR (b) polysomnography demonstrating total 24-hour sleep time ≥ 660 minutes (11 hours)