Xywav — Medical Mutual

Initial criteria

• Patient is age ≥ 18 years
• The patient has tried at least one of modafinil, armodafinil, or methylphenidate
• The patient has been evaluated using polysomnography
• The patient has been evaluated using multiple sleep latency test (MSLT)
• Must be prescribed by or in consultation with 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