Xywav — Medical Mutual

Initial criteria

• Patient is age ≥ 7 years
• Patient has tried two of the following treatments: a CNS stimulant, modafinil, or armodafinil
• If patient is age ≥ 18 years, all of the following must be met: (a) Patient has tried Lumryz or has a contraindication to Lumryz; AND (b) Patient has tried Sunosi or has a contraindication to Sunosi or is currently established on the requested product; AND (c) Patient has tried Wakix or has a contraindication to Wakix or is currently established on the requested product
• 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

Reauthorization criteria

• Response to therapy is required for continuation of therapy

Approval duration

3 months initial; 1 year extended