pitolisant — CareFirst (Caremark)
Cataplexy with narcolepsy
Preferred products
- armodafinil
- modafinil
- amphetamine
- dextroamphetamine
- methylphenidate
Initial criteria
- The diagnosis of narcolepsy is confirmed by a sleep lab evaluation.
- For EDS with narcolepsy: member is age 6 years to <18 years and has experienced inadequate treatment response or intolerance to at least one CNS stimulant (e.g., amphetamine, dextroamphetamine, methylphenidate) OR has a contraindication to at least one CNS stimulant.
- For EDS with narcolepsy: member is age ≥18 years and has experienced inadequate treatment response or intolerance to armodafinil or modafinil OR has contraindications to both armodafinil and modafinil.
- For cataplexy with narcolepsy: diagnosis of narcolepsy is confirmed by a sleep lab evaluation and the member experiences at least 3 cataplexy attacks per week.
- Medication must be prescribed by or in consultation with a sleep specialist (e.g., neurologist experienced with sleep disorders, physician certified in sleep medicine).
Reauthorization criteria
- For EDS with narcolepsy: the member has demonstrated beneficial response to treatment as defined by a decrease in symptoms of daytime sleepiness from baseline.
- For cataplexy with narcolepsy: the member has demonstrated beneficial response to treatment as defined by a decrease in cataplexy episodes from baseline.
Approval duration
12 months