Wakix — Blue Cross Blue Shield of Montana

Preferred products

• armodafinil
• modafinil

Initial criteria

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

Reauthorization criteria

• Patient previously approved for requested agent through plan’s prior authorization process
• AND patient has had clinical benefit with the requested agent
• AND prescriber is specialist in patient’s diagnosis area or has consulted with one
• AND patient does NOT have FDA labeled contraindications to requested agent

Approval duration

12 months