Hetlioz (tasimelteon) — Highmark

Non-24-Hour Sleep-Wake Disorder (Non-24)

Initial criteria

age ≥ 18 years
diagnosis of Non-24-Hour Sleep-Wake Disorder (ICD-10: G47.24)
history of insomnia, excessive daytime sleepiness, or both alternating with asymptomatic episodes
symptoms persisting for at least 3 months
daily sleep logs of at least 14 days showing a sleep/wake pattern that delays each day
sleep disturbance not better explained by another current sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance abuse disorder
member is totally blind and has no light perception
therapeutic failure, contraindication, or intolerance to melatonin
if request is for brand Hetlioz, therapeutic failure or intolerance to generic tasimelteon

prescriber attests member has experienced an increase in total nighttime sleep time OR decrease in daytime nap duration
if request is for brand Hetlioz, therapeutic failure or intolerance to generic tasimelteon

12 months