CurrentAnthemPolicy N/A

Request for Prior Authorization - Hetlioz (tasimelteon)

Prior authorization form and criteria for coverage of Hetlioz (tasimelteon) for members of Indiana Medicaid programs (Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, Indiana PathWays for Aging). Defines initial and reauthorization criteria for non-24-hour sleep-wake disorder (adults) and nighttime sleep disturbances secondary to Smith-Magenis syndrome (pediatric and adult), documentation requirements, and submission/fax instructions.

Policy Summary

PayerAnthem Blue Cross and Blue Shield (Indiana Medicaid programs)

PolicyRequest for Prior Authorization - Hetlioz (tasimelteon)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionPrescribing provider must complete all sections of the form and submit via fax to the specified PA fax numbers; incomplete requests will be returned.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes

2Covered Indications (non-24-hour; Smith-Magenis)

3Age Bands Specified

Coverage Summary

This prior authorization form is for Hetlioz (tasimelteon) and is covered with criteria for Indiana Medicaid members served by Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and Indiana PathWays for Aging. It supports coverage for two covered indications: non-24-hour sleep-wake disorder (adults) and nighttime sleep disturbances secondary to Smith-Magenis syndrome (pediatric and adult). The form specifies age-based thresholds across three bands (adult non-24: ≥ 18 years; Smith-Magenis adult: ≥ 16 years; Smith-Magenis pediatric: 3 years to <16 years) and requires a minimum symptom duration of ≥ 3 months for non-24-hour disorder. Requests must include the requested daily dose and relevant documentation; incomplete forms will be returned. Statistical summary: Covered Indications (non-24-hour; Smith-Magenis): 2; Age Bands Specified: 3.

Authorization Criteria

Initial authorization - Non-24-hour sleep-wake disorder (Adults)

Select ONE of the following:

ALL of the following

Member is 18 years of age or older and has a diagnosis of non-24-hour sleep-wake disorder>= 18 years

Policy Summary

PayerAnthem Blue Cross and Blue Shield (Indiana Medicaid programs)

PolicyRequest for Prior Authorization - Hetlioz (tasimelteon)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionPrescribing provider must complete all sections of the form and submit via fax to the specified PA fax numbers; incomplete requests will be returned.

SourceLink

On This Page

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Initial authorization - Smith-Magenis syndrome (Age 16 and older)

Select ONE of the following:

ALL of the following

Member is 16 years of age or older and has a diagnosis of nighttime sleep disturbances secondary to Smith-Magenis syndrome>= 16 years
Genetic confirmation: Member has had genetic testing confirming Smith-Magenis syndrome (documentation must be submitted)
Documentation must be submitted
Nighttime sleep disturbances experienced by member (for example, frequent nighttime awakenings, shortened and fragmented sleep cycles, etc.) have been documented and submitted with this request
Documentation must be submitted
Requested dose: Prescriber provides requested dose per day
Requested dose must be provided on form

Initial authorization - Smith-Magenis syndrome (Ages 3 to <16)

ALL of the following

Pediatric age range: Member is 3 years of age or older and less than 16 years of age with a diagnosis of nighttime sleep disturbances secondary to Smith-Magenis syndrome>= 3 years and < 16 years
Genetic confirmation: Member has had genetic testing confirming Smith-Magenis syndrome (documentation must be submitted)
Documentation must be submitted
Nighttime sleep disturbances experienced by member (e.g., frequent nighttime awakenings, shortened and fragmented sleep cycles, etc.) have been documented and submitted with this request
Documentation must be submitted
Requested dose: Prescriber provides requested dose per day
Requested dose must be provided on form
Pediatric-specific weight: Prescriber provides member's weight (kg or lb) and date of collection
Weight required for pediatric dosing

Reauthorization - Non-24-hour sleep-wake disorder or Smith-Magenis syndrome

ALL of the following

Clinical response: Submit documentation (for example, current and previous chart notes) showing positive response or stabilization in sleep-wake disorder OR sleep disturbances
Documentation of positive response or stabilization required
Requested dose: Provide requested dose per day
Requested dose must be provided on form
Pediatric-specific: For members under 16 years, provide member's weight (kg or lb) and date of collection
Weight required for pediatric dosing

Provider Actions & Submission

Prior Authorization

Submit completed prior authorization form

Prescribing provider must complete all sections of the form and submit via fax to the specified PA fax numbers; incomplete requests will be returned.

Documentation Required

Submit documentation of diagnosis and confirmation

Provide documentation of total blindness for non-24-hour sleep-wake disorder, genetic testing confirming Smith-Magenis syndrome, and documentation of symptom duration and symptom description as specified.

Confirmation of total blindness (for non-24-hour sleep-wake disorder)
Genetic testing confirming Smith-Magenis syndrome
Documentation of symptom duration and description (e.g., persistent symptoms >= 3 months for non-24-hour; nighttime sleep disturbances such as frequent awakenings, shortened/fragmented sleep cycles for Smith-Magenis)

Documentation Required

Provide evidence of clinical response for reauthorization

Submit current and previous chart notes showing positive response or stabilization for reauthorization requests.

Current and previous chart notes documenting positive response or stabilization
Requested dose per day (must be provided on form)
For pediatric members, include weight (kg or lb) and date of collection when applicable

Billing Rule

Fax submission channels

Fax prior authorization requests to the PA fax numbers shown on the form.

844-864-7860 (retail)
888-209-7838 (medical injectable)

Background

Background: This is a prior authorization request form for Hetlioz (tasimelteon). It covers non-24-hour sleep-wake disorder in adults, which requires confirmation that the member is totally blind (documentation must be submitted), and nighttime sleep disturbances secondary to Smith-Magenis syndrome for both adults and children with specified age bands. The form includes a pediatric-specific weight requirement for Smith-Magenis patients aged 3 to <16 years — the prescriber must provide the member's weight (kg or lb) and date of collection. Required documentation includes confirmation of total blindness for non-24 disorder, genetic testing confirming Smith-Magenis syndrome, documentation of symptom duration and symptom description (examples provided), and for reauthorization, current and prior chart notes showing positive response or stabilization. The prescribing provider must complete all sections and fax the form to the indicated PA fax numbers; incomplete requests will be returned.

OpenPayer

Request for Prior Authorization - Hetlioz (tasimelteon)

Coverage Summary

Authorization Criteria

Coding

Provider Actions & Submission

Background