pitolisant — Blue Cross Blue Shield of Kansas

excessive daytime sleepiness associated with narcolepsy

Preferred products

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. The patient has ONE of the following: A. Has tried and had an inadequate response to armodafinil OR modafinil OR B. Has an intolerance or hypersensitivity to armodafinil OR modafinil OR C. Has an FDA labeled contraindication to BOTH armodafinil AND modafinil OR D. Has been prescribed the requested non-controlled agent due to comorbid conditions OR concerns about controlled substance use AND
3. 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 for the requested agent OR B. There is support for using the requested agent for the patient’s age for the requested indication AND
4. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist, psychiatrist, sleep disorder specialist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
5. The patient does NOT have any FDA labeled contraindications to the requested agent

1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process [Note: patients not previously approved for the requested agent will require initial evaluation review] AND
2. The patient has had clinical benefit with the requested agent AND
3. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist, psychiatrist, sleep disorder specialist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
4. The patient does NOT have any FDA labeled contraindications to the requested agent

12 months