Sutter Health Plus
Provigil (modafinil)
Drugs for the Nervous System : Drugs for Sleep Disorder
  • PA_APPLIES
  • Quantity Limit: 30 day supply per 1 fill(s).
  • Prior Authorization: Endometrial Cancer:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 18
    Duration: 12 Month(s)
    Reauthorization Required: Yes

    Hepatocellular Carcinoma:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 12 Month(s)

    Kidney Cancer:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 1 plan year
    Reauthorization Required: Yes

    Thyroid Carcinoma:
    Age Requirement: >= 18
    Duration: 12 Month(s)

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