Hetlioz — Medical Mutual

Preferred products

• generic tasimelteon

Initial criteria

• Patient is age ≥ 3 years
• If age 3 to 15 years, will use Hetlioz oral suspension formulation
• If age ≥ 16 years, will use Hetlioz capsule
• Molecular genetic testing has confirmed mutation or microdeletion of chromosome 17p11.2 indicative of Smith-Magenis Syndrome
• Hetlioz is prescribed by, or in consultation with, a physician who specializes in sleep disorders, a neurologist, or medical geneticist
• If Brand Hetlioz is requested, patient must have tried generic tasimelteon AND provider attests brand required due to formulation difference in inactive ingredients causing potential allergy or serious adverse reaction

Reauthorization criteria

• Patient has received at least 6 months of continuous Hetlioz therapy under supervision of a sleep specialist, neurologist or medical geneticist
• Prescriber attests patient has achieved adequate results with Hetlioz therapy

Approval duration

initial 6 months; reauth 12 months