Lumryz — Medical Mutual

Initial criteria

• Patient is age ≥ 7 years
• Patient has been evaluated using polysomnography and a multiple sleep latency test
• Diagnosis of narcolepsy has been confirmed according to the prescriber
• The medication has been prescribed by a sleep specialist physician or a neurologist
• Patient meets ONE of the following: (i) Patient has tried dextroamphetamine; OR (ii) Patient has a contraindication or intolerance to dextroamphetamine, according to the prescriber

Reauthorization criteria

• Response to therapy is required for continuation of therapy

Approval duration

3 months initial; 1 year extended