Xywav — United Healthcare

Initial criteria

• Diagnosis of narcolepsy without cataplexy (i.e., Narcolepsy Type 2) as confirmed by sleep study (unless the prescriber provides justification confirming that a sleep study would not be feasible)
• AND Symptoms of excessive daytime sleepiness (including but not limited to daily periods of irrepressible need to sleep or daytime lapses into sleep) are present
• AND Cataplexy is absent

Reauthorization criteria

• Reduction in symptoms of excessive daytime sleepiness associated with therapy

Approval duration

Initial: 6 months; Reauthorization: 12 months