Hetlioz — CareFirst (Caremark)
Non-24-Hour Sleep-Wake Disorder (Non-24)
Initial criteria
- Diagnosis of total blindness in both eyes (e.g., nonfunctioning retinas)
- Member is not able to perceive light in either eye
- Member is experiencing difficulty initiating sleep, difficulty awakening in the morning, or excessive daytime sleepiness
- Prescribed by or in consultation with a sleep specialist (e.g., neurologist experienced with sleep disorders, physician certified in sleep medicine) or psychiatrist
Reauthorization criteria
- Diagnosis of total blindness in both eyes (e.g., nonfunctioning retinas)
- Member is not able to perceive light in either eye
- Member is experiencing increased total nighttime sleep and/or decreased daytime nap duration
Approval duration
Initial: 6 months; Reauthorization: 12 months