Modafinil (Provigil®) Prior Authorization Criteria

Modafinil (Provigil®) Authorization Request Form

Covered Uses

All FDA approved indications not otherwise excluded from Part D

• Improve wakefulness in adult patients with excessive sleepiness associated with narcolepsy, obstructive sleep apnea/hypopnea syndrome and shift work sleep disorder

Exclusion Criteria

Use as monotherapy for obstructive sleep apnea/hypopnea syndrome (OSAHS)

Required Medical Information

Certify that patient is using continuous positive airway pressure (CPAP)

Age Restrictions

Patients 17 years of age and older

Prescriber Restrictions

• Neurologist
• Pulmonologist
• Pneumologist
• Psychiatrist

Coverage Duration

Three (3) months

Other Criteria

None