Xywav — Medical Mutual

Initial criteria

• Patient is age ≥ 7 years
• Narcolepsy has been confirmed with polysomnography and a multiple sleep latency test
• Sodium oxybate/Xywav has been prescribed by a sleep disorder specialist, pulmonologist, psychiatrist, or 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
• The patient has tried BOTH of the following: (a) Wakix or has a contraindication to Wakix or is currently established on the requested product; AND (b) Lumryz or has a contraindication to Lumryz

Reauthorization criteria

• Response to therapy is required for continuation of therapy

Approval duration

3 months initial; 1 year extended