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Does the client have a diagnosis of obstructive sleep apnea in the last 730 days? [ ] Yes Vilafinil (Go to #6) 6 .
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Is the dose less than or equal to (≤) 250mg per day? [ ] Yes (Approve – 365 days) Copyright © 2019 Health Information Designs, LLC Texas Prior Authorization Program Clinical Criteria Provigil and Nuvigil Clinical Criteria Logic Diagram Is the client ≥ 16 years Does the client have a diagnosis of shift work disorder in the last 730 Is the dose ≤ 150mg Does the client have a diagnosis of narcolepsy in the last 730 days? Does the client have a diagnosis of obstructive sleep apnea in the last Does the client have a procedure code for CPAP or BiPAP in the Is the dose ≤ 250mg Copyright © 2019 Health Information Designs, LLC Texas Prior Authorization Program Clinical Criteria Provigil and Nuvigil Clinical Criteria Supporting Tables Step 2 (diagnosis of shift work disorder) Required diagnosis: 1 Look back timeframe: 730 days OTHER SLEEP DISORDERS NOT DUE TO provigil drug price adrafinil or modafinil provigil long term use side effects modafinil max dose A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION CIRCADIAN RHYTHM SLEEP DISORDER, SHIFT WORK TYPE Step 4 (diagnosis of narcolepsy) Required diagnosis: 1 Look back timeframe: 730 days NARCOLEPSY WITH CATAPLEXY NARCOLEPSY WITHOUT CATAPLEXY NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE WITH NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT Step 5 (diagnosis of obstructive sleep apnea) Required quantity: 1 Look back timeframe: 730 days For the list of diagnosis codes that pertain to this step, see the Obstructive Sleep Apnea table in the previous “Supporting Tables” section .
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