Xywav — United Healthcare

Initial criteria

• Submission of medical records documenting diagnosis of idiopathic hypersomnia with BOTH:
• - Patient has daily periods of irrepressible need to sleep or daytime lapses into sleep for ≥3 months
• - Mean sleep latency <8 minutes and fewer than two SOREMPs on MSLT (per standard techniques after normal overnight polysomnogram) OR no SOREMPs if REM latency on prior PSG <15 minutes
• Physician attestation that other causes of sleepiness ruled out or treated (e.g., obstructive sleep apnea, insufficient sleep, shift work, substances/medication withdrawal, sleep phase disorder, other sleep disorders)
• History of failure, contraindication, or intolerance of ALL:
• - One of: amphetamine-based stimulant (e.g., amphetamine, dextroamphetamine) OR methylphenidate-based stimulant
• - One of: modafanil (Provigil) OR armodafanil (Nuvigil)
• Prescribed by Neurologist OR Psychiatrist OR Pulmonologist OR Sleep Medicine Specialist

Reauthorization criteria

• Documentation demonstrating reduction in symptoms of excessive daytime sleepiness

Approval duration

Initial: 3 months; Reauth: 12 months