Download MHCP Enrolled Providers – Pharmacies Fee-for

MHCP Enrolled Providers – Pharmacies
Fee-for-Service PA Criteria Sheet – Provigil/Nuvigil
(April 2012)
Drug
Provigil (modafinil) [Cephalon]
Nuvigil (armodafinil) [Cephalon]
Therapeutic Area
narcolepsy
Brand Provigil is preferred over the generic equivalent.
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Payment for Provigil or Nuvigil will be authorized if the recipient:
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Nuvigil
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Is at least 16 years of age AND
Has a diagnosis of narcolepsy OR
Has a diagnosis of Multiple Sclerosis and suffers from fatigue OR
Has excessive sleepiness associated with obstructive sleep apnea AND is not also taking a drug to improve sleep (e.g.,
Ambien, Lunesta, Sonata, Rozerem) AND is compliant with CPAP therapy whenever possible OR
Has excessive sleepiness associated with shift work sleep disorder and is employed
Nuvigil is marketed to be a once daily drug. There is a QL of one per day on Nuvigil. Quantities greater than 1 per day will
NOT be approved
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Provigil
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The Department requires tablet splitting for the 200 mg dose under the tablet splitting criteria. Both the 200 mg and 100
mg Provigil tablets are under PA restrictions. However, 100 mg tablets should be authorized only if the dose can’t be
achieved using a 200 mg tablet
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Provigil Tablet Splitting Criteria
PA will be authorized if:
 Prescribed dose cannot be achieved using the appropriate higher-strength tablet, with instructions to split the tablet in half
 The recipient cannot understand the tablet splitting process
 The recipient has a mental health diagnosis that makes it dangerous for them to change the dose from a whole tablet to a
half tablet, PA can be granted
 The recipient is simply unable to break a tablet in half, this is not an adequate reason to grant a prior authorization. The
pharmacy or caregiver should be encouraged to break the tablet in half for the recipient
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Products are subject to quantity limits, prior authorization and tablet splitting requirements. Generic modafinil requires prior
authorization and Brand Preferred criteria must be met for authorization.
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MHCP Provider Call Center (651) 431-2700 or 1-800-366-5411