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Provigil (modafinil) — Highmark

Narcolepsy

Preferred products

  • generic armodafinil
  • generic modafinil
  • plan-preferred generic CNS stimulant (e.g., dextroamphetamine, methylphenidate)

Initial criteria

  • age ≥ 18 years
  • diagnosis of narcolepsy (ICD-10: G47.41)
  • meets ONE of the following: (a) multiple sleep latency test (MSLT) substantiating mean sleep latency ≤ 8 minutes AND ≥ 2 SOREMPs; OR (b) polysomnography and MSLT showing mean sleep latency ≤ 8 minutes AND ≥ one SOREMP on MSLT AND ≥ one SOREMP on polysomnography; OR (c) documented hypocretin-1 deficiency defined as cerebrospinal fluid hypocretin-1 < 110 pg/mL OR < one-third of the normal value based on laboratory reference range
  • documentation of baseline excessive daytime sleepiness (EDS) via Epworth Sleepiness Scale (ESS) OR Maintenance of Wakefulness Test (MWT)
  • therapeutic failure, intolerance, or contraindication to a plan-preferred generic CNS stimulant (for example, dextroamphetamine, methylphenidate)
  • IF request is for brand Provigil: therapeutic failure or intolerance to plan-preferred generic armodafinil AND generic modafinil
  • IF request is for brand Nuvigil: therapeutic failure or intolerance to generic armodafinil AND generic modafinil

Reauthorization criteria

  • member has experienced a decrease in daytime sleepiness with narcolepsy as documented by improvement on the Epworth Sleepiness Scale (ESS) or Maintenance of Wakefulness Test (MWT) compared to baseline