Wakix (pitolisant) prior authorization / medical necessity
Defines initial and reauthorization medical necessity criteria, prescriber requirements, and documentation requirements for coverage of Wakix (pitolisant) for narcolepsy (with and without cataplexy) including pediatric indication (6+). Includes allowance for automated approvals based on prior claims/diagnosis and notes authorization duration and supply limits.
Annual review and updated references performed in 9/2025; effective date 11/16/2025.
Added requirement for submission of documentation of sleep study with specific sleep study requirements (mean sleep latency ≤ 8 minutes and ≥2 SOREMPs).
Added requirement for prescriber specialty (Neurologist, Psychiatrist, Pulmonologist; Sleep Medicine Specialist for Type 1).
Added requirement for history of Sunosi failure/intolerance as alternate prior therapy.
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