Hetlioz LQ oral suspension (tasimelteon) — Point32Health

Initial criteria

• Documented diagnosis of nighttime sleep disturbances in Smith-Magenis Syndrome (SMS)
• One of the following: (a) Patient age 3–15 years OR (b) Patient age ≥ 16 years and prescriber provides medical necessity for use
• Prescribed by a specialist in sleep disorders

Reauthorization criteria

• Documented diagnosis of Non-24 sleep-wake disorder or Smith-Magenis Syndrome
• Documentation the patient is totally blind (has no light perception) if used for Non-24 sleep-wake disorder
• Prescribed by or in consultation with a specialist in sleep disorders
• Documentation of continued positive clinical response to therapy

Approval duration

initial 4 months; reauth 12 months