Provigil (modafinil) — Highmark
Obstructive Sleep Apnea/Hypopnea Syndrome (OSAHS)
Preferred products
- generic armodafinil
Initial criteria
- age ≥ 18 years
- Diagnosis of obstructive sleep apnea/hypopnea syndrome (ICD-10: G47.33)
- Member meets one (1) of the following (a. or b.): a. Currently receiving and compliant with positive airway pressure (PAP) OR b. Has experienced therapeutic failure, intolerance, or contraindication to PAP AND is currently using and compliant with a custom, titratable oral appliance
- 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 meets one (1) of the following (a. or b.): a. Currently receiving and compliant with positive airway pressure (PAP) OR b. Has experienced therapeutic failure, intolerance, or contraindication to PAP AND is currently using and compliant with a custom, titratable oral appliance
- Member's symptoms of fatigue have improved
Approval duration
12 months