Armodafinil and Modafinil Prior Authorization (with Quantity Limit) Criteria – Medicare Part D

Prior Authorization and Quantity Limit Criteria for Approval

Armodafinil or modafinil will be approved when ALL of the following are met:

1. The patient is at least 17 years of age
   AND
2. The patient has an FDA labeled indication or an indication that is supported in CMS approved compendia for the requested medication
   AND 
3. The patient will NOT be using the requested medication in combination with another target medication (i.e., armodafinil OR modafinil)
   AND
4. ONE of the following:
   1. The requested quantity (dose) does NOT exceed the program quantity limit
      OR
   2. ALL of the following:
      1. The requested quantity (dose) is greater than the program quantity limit
         AND
      2. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit
         AND
      3. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 12 months