Wakix — Blue Cross Blue Shield of Illinois

Preferred products

• armodafinil
• modafinil

Initial criteria

• 1. The patient has ONE of the following: A. Has a diagnosis of excessive daytime sleepiness associated with narcolepsy OR B. Has a diagnosis of cataplexy associated with narcolepsy AND
• 2. ONE of the following: A. BOTH of the following: 1. ONE of the following: A. The patient has stage four advanced metastatic cancer and the requested agent is being used to treat the cancer OR B. The patient has stage four advanced metastatic cancer and the requested agent is being used to treat an associated condition related to stage four advanced metastatic cancer AND 2. The use of the requested agent is consistent with best practices and FDA approved OR B. ONE of the following: 1. The request is for a BCBS IL Fully Insured, ASO Cost/BBF, HIM, or Non-ERISA ASO/Self-insured Municipalities/Counties member OR 2. The patient is currently being treated with and stable on the requested agent OR 3. The patient has tried and had an inadequate response to armodafinil OR modafinil OR 4. Armodafinil OR modafinil was discontinued due to lack of efficacy or adverse event OR 5. The patient has an intolerance or hypersensitivity to armodafinil OR modafinil OR 6. The patient has an FDA labeled contraindication to BOTH armodafinil AND modafinil OR 7. Armodafinil OR modafinil is expected to be ineffective or cause harm based on patient characteristics OR 8. Armodafinil OR modafinil is not in the best interest of the patient based on medical necessity OR 9. The patient tried another drug in the same class as armodafinil or modafinil and discontinued due to lack of efficacy or adverse event OR 10. The patient has been prescribed the requested non-controlled agent due to comorbid conditions or concerns about controlled substance use
• 3. The patient has been evaluated using polysomnography and/or a Multiple Sleep Latency Test
• 4. If the patient has an FDA labeled indication, then ONE of the following: A. The patient’s age is within FDA labeling for the requested indication OR B. There is support for use at patient’s age for the requested indication
• 5. The prescriber is a specialist in the area of diagnosis (neurologist, psychiatrist, or sleep disorder specialist) or has consulted with one
• 6. The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• 1. The patient has been previously approved through the plan’s Prior Authorization process
• 2. The patient has had clinical benefit with the requested agent
• 3. The prescriber is a specialist in the area of the patient’s diagnosis or has consulted with a specialist
• 4. The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months