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Is the dose less than or equal to (≤) 200mg 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 narcolepsy or shift work disorder in the last 730 days? Does the client have a diagnosis of obstructive sleep apnea in the last Does the client have a diagnosis of severe hepatic impairment in the last 365 days? Is the dose ≤ 100mg Does the client have a procedure code for CPAP or BiPAP in the Is the dose ≤ 200mg Copyright © 2019 Health Information Designs, LLC Texas Prior Authorization Program Clinical Criteria Provigil and Nuvigil Clinical Criteria Supporting Tables Step 2 (diagnosis of narcolepsy or shift work disorder) Required diagnosis: 1 Look back timeframe: 730 days OTHER SLEEP DISORDERS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION CIRCADIAN RHYTHM SLEEP DISORDER, SHIFT WORK TYPE NARCOLEPSY WITH CATAPLEXY NARCOLEPSY WITHOUT CATAPLEXY NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE WITH NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT Step 3 (diagnosis of obstructive sleep apnea) Required diagnosis: 1 Look back timeframe: 730 days SLEEP APNEA, UNSPECIFIED OBSTRUCTIVE SLEEP APNEA (ADULT) (PEDIATRIC) Step 4 (procedure code for CPAP or BiPAP) Required procedure: 1 Look back timeframe: 730 days CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) CPAP INITIATION AND MANAGEMENT SLEEP STAGING WITH INITIATION OF CPAP CPAP WITH BI-LEVEL FAILURE CPAP WITH BI-LEVEL FAILURE CPAP WITH BI-LEVEL FAILURE Copyright © 2019 Health Information Designs, LLC Texas Prior Authorization Program Clinical Criteria Provigil and Nuvigil Step 5 (diagnosis of clinically-significant hepatic impairment) Required diagnosis: 1 Look back timeframe: 365 days HEPATITIS A WITH HEPATIC COMA HEPATITIS A WITHOUT HEPATIC COMA ACUTE HEPATITIS B WITH DELTA-AGENT WITH HEPATIC COMA ACUTE HEPATITIS B WITH DELTA-AGENT WITHOUT HEPATIC COMA ACUTE HEPATITIS B WITHOUT DELTA-AGENT WITH HEPATIC COMA ACUTE HEPATITIS B WITHOUT DELTA-AGENT AND WITHOUT HEPATIC ACUTE DELTA-(SUPER) INFECTION OF HEPATITIS B CARRIER ACUTE HEPATITIS C WITHOUT HEPATIC COMA ACUTE HEPATITIS C WITH HEPATIC COMA ACUTE HEPATITIS E OTHER SPECIFIED ACUTE VIRAL HEPATITIS ACUTE VIRAL HEPATITIS, UNSPECIFIED CHRONIC VIRAL HEPATITIS B WITH DELTA-AGENT CHRONIC VIRAL HEPATITIS B WITHOUT DELTA-AGENT CHRONIC VIRAL HEPATITIS C OTHER CHRONIC VIRAL HEPATITIS CHRONIC VIRAL HEPATITIS, UNSPECIFIED UNSPECIFIED VIRAL HEPATITIS WITH HEPATIC COMA UNSPECIFIED VIRAL HEPATITIS B WITHOUT HEPATIC COMA UNSPECIFIED VIRAL HEPATITIS B WITH HEPATIC COMA UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA UNSPECIFIED VIRAL HEPATITIS C WITH HEPATIC COMA UNSPECIFIED VIRAL HEPATITIS WITHOUT HEPATIC COMA CYTOMEGALOVIRAL HEPATITIS ALCOHOLIC FATTY LIVER ALCOHOLIC HEPATITIS WITHOUT ASCITES ALCOHOLIC HEPATITIS WITH ASCITES ALCOHOLIC FIBROSIS AND SCLEROSIS OF LIVER ALCOHOLIC CIRRHOSIS OF LIVER WITHOUT ASCITES ALCOHOLIC CIRRHOSIS OF LIVER WITH ASCITES ALCOHOLIC HEPATIC FAILURE WITHOUT COMA ALCOHOLIC HEPATIC FAILURE WITH COMA ALCOHOLIC LIVER DISEASE, UNSPECIFIED TOXIC LIVER DISEASE WITH CHOLESTASIS TOXIC LIVER DISEASE WITH HEPATIC NECROSIS, WITHOUT COMA Copyright © 2019 Health Information Designs, LLC Texas Prior Authorization Program Clinical Criteria Provigil and Nuvigil Step 5 (diagnosis of clinically-significant hepatic impairment) Required diagnosis: 1 Look back timeframe: 365 days TOXIC LIVER DISEASE WITH HEPATIC NECROSIS, WITH COMA TOXIC LIVER DISEASE WITH ACUTE HEPATITIS TOXIC LIVER DISEASE WITH CHRONIC PERSISTENT HEPATITIS TOXIC LIVER DISEASE WITH CHRONIC LOBULAR HEPATITIS TOXIC LIVER DISEASE WITH CHRONIC ACTIVE HEPATITIS WITHOUT TOXIC LIVER DISEASE WITH CHRONIC ACTIVE HEPATITIS WITH TOXIC LIVER DISEASE WITH HEPATITIS, NOT ELSEWHERE CLASSIFIED TOXIC LIVER DISEASE WITH FIBROSIS AND CIRRHOSIS OF LIVER TOXIC LIVER DISEASE WITH OTHER DISORDERS OF LIVER TOXIC LIVER DISEASE, UNSPECIFIED ACUTE AND SUBACUTE HEPATIC FAILURE WITH COMA CHRONIC HEPATIC FAILURE WITHOUT COMA CHRONIC HEPATIC FAILURE WITH COMA HEPATIC best modafinilcat product modafinil mode d’action modafinil online bestellen Buy provigil Online FAILURE, UNSPECIFIED WITHOUT COMA HEPATIC FAILURE, UNSPECIFIED WITH COMA CHRONIC PERSISTENT HEPATITIS, NOT ELSEWHERE CLASSIFIED CHRONIC LOBULAR HEPATITIS, NOT ELSEWHERE CLASSIFIED CHRONIC ACTIVE HEPATITIS, NOT ELSEWHERE CLASSIFIED OTHER CHRONIC HEPATITIS, NOT ELSEWHERE CLASSIFIED CHRONIC HEPATITIS, UNSPECIFIED HEPATIC FIBROSIS HEPATIC SCLEROSIS HEPATIC FIBROSIS WITH HEPATIC SCLEROSIS PRIMARY BILIARY CIRRHOSIS SECONDARY BILIARY CIRRHOSIS BILIARY CIRRHOSIS, UNSPECIFIED UNSPECIFIED CIRRHOSIS OF LIVER OTHER CIRRHOSIS OF LIVER ABSCESS OF LIVER PHLEBITIS OF PORTAL VEIN NONSPECIFIC REACTIVE HEPATITIS GRANULOMATOUS HEPATITIS, NOT ELSEWHERE CLASSIFIED NONALCOHOLIC STEATOHEPATITIS (NASH) OTHER SPECIFIED INFLAMMATORY LIVER DISEASES Copyright © 2019 Health Information Designs, LLC Texas Prior Authorization Program Clinical Criteria Provigil and Nuvigil Step 5 (diagnosis of clinically-significant hepatic impairment) Required diagnosis: 1 Look back timeframe: 365 days INFLAMMATORY LIVER DISEASE, UNSPECIFIED FATTY (CHANGE OF) LIVER, NOT ELSEWHERE CLASSIFIED CHRONIC PASSIVE CONGESTION OF LIVER INFARCTION OF LIVER PELIOSIS HEPATIS HEPATIC VENO-OCCLUSIVE DISEASE PORTAL HYPERTENSION HEPATORENAL SYNDROME OTHER SPECIFIED DISEASES OF LIVER LIVER DISEASE, UNSPECIFIED LIVER DISORDERS IN DISEASES CLASSIFIED ELSEWHERE Copyright © 2019 Health Information Designs, LLC Texas Prior Authorization Program Clinical Criteria Provigil and Nuvigil Drugs Requiring Prior Authorization The listed GCNS may not be an indication of TX Medicaid Formulary coverage .

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