Provigil
| Covered Uses: | All FDA-approved indications not otherwise excluded from Part D. |
| Exclusion Criteria: | |
| Required Medical Information: | For narcolepsy, the prescriber must confirm that the patient does not have underlying conditions that may contribute to excessive sleepiness (e.g., nocturnal myoclonus, current drug therapy which affects sleep or contributes to daytime sedation, or chronic voluntary or involuntary sleep deprivation through shift-work) OR any underlying conditions have been addressed and treated. Coverage is provided for SWSD when: (1) Prescriber must confirm that the patient is a night worker and (2) has complaints of persistent and frequent excessive sleepiness and/or falling asleep while at work and (3) any medical conditions known to cause or contribute to sleepiness have been considered and treated. Coverage is provided for idiopathic hypersomnolence that is confirmed by polysomnography where excessive sleepiness is not due to other sleep disorders such as narcolepsy, obstructive sleep apnea or posttraumatic hypersomnia. |
| Age Restrictions: | |
| Prescriber Restrictions: | |
| Coverage Duration: | 12 months |
| Other Criteria: | For OSAHS, coverage is provided for patients who are receiving nasal continuous positive airway pressure therapy (CPAP) or who are not candidates for CPAP. Coverage is provided for depression associated with fatigue and/or sleepiness when the patient is receiving antidepressant therapy |
| Excluded Drug Criteria: |
Last Modified on 12/19/2012