Hetlioz LQ (tasimelteon) — Highmark
Nighttime Sleep Disturbances in Smith-Magenis Syndrome (SMS)
Initial criteria
- age 3–15 years
- diagnosis of Smith-Magenis Syndrome confirmed by deletion of chromosome 17p11.2 OR variant in RAI1 gene
- member experiencing nighttime sleep disturbances including difficulty falling asleep, shortened sleep cycles, inability to enter REM sleep, or frequent awakening during the night and early in the morning
Reauthorization criteria
- member is between 3 and 15 years of age
- prescriber attests member has experienced an increase in total nighttime sleep time OR increase in sleep quality
Approval duration
12 months