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PRIOR AUTHORIZATION DRUG ATTACHMENT FOR MODAFINIL AND NUVIGIL
2 of 4
F-00079 (01/2017)
SECTION III A – CLINICAL INFORMATION FOR NARCOLEPSY WITH CATAPLEXY OR WITHOUT CATAPLEXY (Continued)
18. Has the member had an overnight polysomogram (PSG) sleep study followed
by a multiple sleep latency test (MSLT)?
Yes
No
Test results and provider interpretation for the PSG and MSLT, along with medical record documentation supporting a clinical
correlation between the test results and a diagnosis of narcolepsy, must be submitted with this PA request for consideration.
19. Is the member taking any sedative hypnotics?
Yes
No
20. Is the member taking central nervous system (CNS) depressants (i.e., anxiolytics,
barbiturates, or opioids)?
Yes
No
If yes, indicate the CNS depressants and daily doses.
1.
2.
3.
Are any of the above listed CNS depressants contributing to the member’s daytime
sleepiness?
Yes
No
If no, indicate how the prescriber evaluated the CNS depressants and determined they are not contributing to the member’s
daytime sleepiness.
SECTION III B – CLINICAL INFORMATION FOR OBSTRUCTIVE SLEEP APNEA / HYPOPNEA SYNDROME (OSAHS)
21. Does the member have OSAHS?
Yes
No
22. Has the member had an overnight PSG sleep study?
Yes
No
Test results and provider interpretation for the PSG must be submitted with this PA request for consideration.
23. What is the member’s Apnea-Hypopnea Index (AHI)?
Events / Hour
24. Has the member tried continuous positive airway pressure (CPAP)?
Yes
No
SECTION III C – CLINICAL INFORMATION FOR SHIFT WORK SLEEP DISORDER
25. Does the member have shift work sleep disorder?
Yes
No
26. Is the member a night-shift worker?
Yes
No
27. Indicate the member’s current employer and weekly work schedule.
28. Is the member taking any sedative hypnotics?
Yes
No
Continued

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