Hetlioz — Medical Mutual

Preferred products

• generic tasimelteon

Initial criteria

• Patient is age ≥ 18 years
• Patient is totally blind with no perception of light
• Medication is prescribed by, or in consultation with, a physician who specializes in the treatment of sleep disorders
• Diagnosis of Non-24 is confirmed by ONE of the following (assessment of at least one physiologic circadian phase marker OR actigraphy performed for ≥ 1 week plus evaluation of sleep logs recorded for ≥ 1 month)
• Patient has received at least 6 months of continuous melatonin therapy under a sleep specialist AND did not achieve adequate results with melatonin therapy (e.g., entrainment, clinically meaningful increases in nighttime sleep, clinically meaningful decreases in daytime sleep)
• 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 is age ≥ 18 years
• Patient is totally blind with no perception of light
• Medication is prescribed by, or in consultation with, a physician who specializes in the treatment of sleep disorders
• Patient has received at least 6 months of continuous Hetlioz therapy under supervision of a sleep specialist
• Patient has achieved adequate results with Hetlioz therapy according to the prescribing physician (e.g., entrainment, improved nighttime sleep, decreased daytime sleep)

Approval duration

initial 6 months; reauth 12 months