Subject: Wakix 3176-A SGM P2023
Policy:
I. INDICATIONS
The indications below including FDA-approved indications and
compendial uses are considered a covered benefit provided that
all the approval criteria are met and the member has no
exclusions to the prescribed therapy.
FDA-Approved Indication
Wakix is indicated for the treatment of excessive daytime
sleepiness (EDS) or cataplexy in adult patients with narcolepsy.
All other indications are considered experimental/investigational
and not medically necessary.
II. DOCUMENTATION
Submission of the following information is necessary to initiate
the prior authorization review:
A. For initial requests, all of the following (if applicable):
1. Documentation of a sleep lab evaluation.
2. Chart notes, medical record documentation, or claims
history supporting previous medications tried (if
applicable), including response to therapy. If therapy is
not advisable, documentation of clinical reason to avoid
therapy.
B. For continuation requests, chart notes or medical record
documentation supporting a beneficial response to therapy
(e.g., decrease in daytime sleepiness, decrease in cataplexy
episodes from baseline).
III. PRESCRIBER SPECIALTIES
This medication must be prescribed by or in consultation with a
sleep specialist (e.g., neurologist experienced with sleep
disorders, physician certified in sleep medicine).
IV. CRITERIA FOR INITIAL APPROVAL
A. Excessive Daytime Sleepiness with Narcolepsy
Authorization of 12 months may be granted for treatment of
excessive daytime sleepiness (EDS) in adult patients with
narcolepsy when all of the following criteria are met:
1. The diagnosis of narcolepsy is confirmed by a sleep lab
evaluation.
2. The member has experienced an inadequate treatment
response, intolerance to armodafinil or modafinil OR the
member has a contraindication to both armodafinil and
modafinil.
B. Cataplexy with Narcolepsy
Authorization of 12 months may be granted for the treatment
of cataplexy in adult patients with narcolepsy when all of the
following criteria are met:
1. The diagnosis of narcolepsy is confirmed by a sleep lab
evaluation.
2. The member experiences at least 3 cataplexy attacks per
week.
IV. CONTINUATION OF THERAPY
A. Excessive Daytime Sleepiness with Narcolepsy
Authorization of 12 months may be granted for continued
treatment of excessive daytime sleepiness (EDS) with
narcolepsy when the member has demonstrated beneficial
response to treatment as defined by a decrease in symptoms
of daytime sleepiness from baseline.
B. Cataplexy with Narcolepsy
Authorization of 12 months may be granted for continued
treatment of cataplexy with narcolepsy when the member
has demonstrated beneficial response to treatment as
defined by a decrease in cataplexy episodes from baseline.
Place of Service:
Outpatient
The above policy is based on the following references:
- Wakix [package insert]. Plymouth Meeting, PA: Harmony Biosciences, LLC; December 2022.
- Dauvilliers Y, Bassetti C, Lammers GJ, et al. Pitolisant versus placebo or modafinil in patients with narcolepsy: a double-blind, randomised trial. Lancet Neurol. 2013 Nov;12(11):1068-75. doi: 10.1016/S1474-4422(13)70225-4. Epub 2013 Oct 7. Accessed March 10, 2020.
- Fronczek R, Middelkoop HA, van Dijk JG, Lammers GJ. Focusing on vigilance instead of sleepiness in the assessment of narcolepsy: high sensitivity of the Sustained Attention to Response Task (SART). Sleep. 2006 Feb;29(2):187-91. Accessed March 10, 2020.
- Morgenthaler TI, Vishesh KK, Brown T, et al. Practice Parameters for the Treatment of Narcolepsy and other Hypersomnias of Central Origin. Sleep 2007;30(12):1705-11.
- Micromedex (electronic version). Truven Health Analytics, Greenwood Village, Colorado, USA. http://www.micromedexsolutions.com/. Accessed February 24, 2023.
- Maski K, Trotti LM, Kotagal S, Auger RR, et al. Treatment of central disorders of hypersomnolence: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. Published online September 1, 2021.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
October 14, 2023
