Subject: tasimelteon-Hetlioz-Hetlioz LQ 2426-A SGM P2024

Drug

HETLIOZ capsules  (tasimelteon capsules)

HETLIOZ LQ oral suspension  (tasimelteon oral suspension)

tasimelteon

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 Indications
          A.  Non-24-Hour Sleep-Wake Disorder (Non-24):
               Hetlioz capsules are indicated for the treatment of Non-24 in adults.

          B.  Nighttime Sleep Disturbances in Smith-Magenis Syndrome (SMS):
               1.  Hetlioz capsules are indicated for treatment of nighttime sleep disturbances in SMS in
                    patients 16 years of age and older.
               2.  Hetlioz LQ oral suspension is indicated for the treatment of nighttime sleep disturbances
                    in SMS in pediatric patients 3 to 15 years of age.

          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, chart notes or test results to support one of the following:
               1.  Total blindness in both eyes for Non-24-Hour Sleep-Wake Disorder (Non-24), OR
               2.  Smith-Magenis Syndrome.
          B.  For continuation requests, documentation to support one of the following:
               1.  For Non-24-Hour Sleep-Wake Disorder, both of the following:
                    i.     Chart notes or test results confirming total blindness in both eyes.
                    ii.    An increased total nighttime sleep and/or decreased daytime nap duration, OR
               2.  For nighttime sleep disturbances in Smith-Magenis syndrome, both of the following:
                    i.     Chart notes or test results confirming Smith-Magenis Syndrome.
                    ii.    Improvement in quality of sleep such as improvement in sleep efficiency, sleep onset
                           and final sleep offset, or waking after sleep onset.


   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) or
          psychiatrist.


   IV.  CRITERIA FOR INITIAL APPROVAL

          A.  Non-24-Hour Sleep-Wake Disorder
               Authorization of 6 months may be granted for treatment of Non-24-Hour Sleep-Wake
               Disorder when all of the following criteria are met:
               1.  The member has a diagnosis of total blindness in both eyes (e.g., nonfunctioning
                    retinas).
               2.  The member is not able to perceive light in either eye.
               3.  The member is experiencing difficulty initiating sleep, difficulty awakening in the morning,
                    or excessive daytime sleepiness.

          B.  Nighttime Sleep Disturbances in Smith-Magenis Syndrome (SMS)
               Authorization of 6 months may be granted for the treatment of nighttime sleep disturbances
               in Smith-Magenis Syndrome (SMS) when all of the following criteria are met:
               1.  The member has a confirmed clinical diagnosis of Smith-Magenis syndrome.
               2.  The member has a history of sleep disturbances.


    V.  CONTINUATION OF THERAPY

          A.  Non-24-Hour Sleep-Wake Disorder
               Authorization of 12 months may be granted for treatment of Non-24-Hour Sleep-Wake
               Disorder when all of the following criteria are met:
               1.  The member has a diagnosis of total blindness in both eyes (e.g., nonfunctioning
                    retinas).
               2.  The member is not able to perceive light in either eye.
               3.  The member is experiencing increased total nighttime sleep and/or decreased daytime
                    nap duration.

          B.  Nighttime Sleep Disturbances in Smith-Magenis Syndrome (SMS)
               Authorization of 12 months may be granted for the treatment of nighttime sleep
               disturbances in Smith-Magenis syndrome if the member experiences improvement in the
               quality of sleep since starting therapy with the requested drug.

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Hetlioz [package insert]. Washington, D.C.: Vanda Pharmaceuticals, Inc.; January 2023.
2. Tasimelteon [package insert]. Bridgewater, NJ: Amneal Pharmaceuticals; January 2023.
3. Auger, Robert R, Burgess, Helen J, et al. Clinical Practice Guideline for the Treatment of Intrinsic Circadian Rhythm Sleep-Wake Disorders: Advanced Sleep-Wake Phase Disorder (ASWPD), Delayed Sleep-Wake Phase Disorder (DSWPD), Non-24-Hour Sleep-Wake Rhythm Disorder (N24SWD), and Irregular Sleep-Wake Rhythm Disorder (ISWRD). An Update for 2015: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med.2015 Oct;11(10):1199-236.
4.  

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.

June 09, 2024