Xywav — Highmark
idiopathic hypersomnia (IH)
Preferred products
- generic modafinil
- generic CNS stimulant (e.g., methylphenidate, amphetamine salts)
Initial criteria
- age ≥ 18 years
- diagnosis of idiopathic hypersomnia (ICD-10: G47.11 or G47.12)
- no diagnosis of cataplexy
- polysomnography and/or MSLT substantiating < 2 SOREMPs
- ONE of the following: (a) MSLT demonstrating mean sleep latency ≤ 8 minutes; OR (b) polysomnography demonstrating total 24‑hour sleep time ≥ 660 minutes (11 hours); OR (c) wrist actigraphy demonstrating ≥ 660 minutes (11 hours) of sleep per 24 hours averaged across ≥ 7 days of monitoring
- documentation of baseline excessive daytime sleepiness (EDS) via Epworth Sleepiness Scale (ESS) OR Maintenance of Wakefulness Test (MWT)
- therapeutic failure, contraindication, or intolerance to ALL of the following plan‑preferred products: (a) generic modafinil AND (b) generic CNS stimulant (e.g., methylphenidate, amphetamine salts)
Reauthorization criteria
- prescriber attests member has experienced a decrease in daytime sleepiness as documented by improvement on Epworth Sleepiness Scale (ESS) or Maintenance of Wakefulness Test (MWT) compared to baseline
Approval duration
12 months