CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Hetlioz (tasimelteon) Prior Authorization — Coverage Criteria

This document is a payer prior authorization form and checklist for Hetlioz (tasimelteon) used to request coverage for members; it applies to prescribers submitting authorization requests to Neighborhood Health Plan of Rhode Island (participating physicians/providers).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHetlioz (tasimelteon) Prior Authorization — Coverage Criteria

Policy CodePolicy N/A

Change TypeForm/criteria maintenance

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed Hetlioz prior authorization form with required supporting clinical documentation (fax to 1-866-423-0945 or use Cover My Meds).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6checklist questions

1-866-423-0945fax

401-427-8200pharmacy phone

Cover My Medsportal

Coverage Criteria and Form Requirements

Form-based coverage criteria

Coverage requires completion of the form and affirmative responses with supporting documentation where specified.

Main authorization requirements

Diagnostic indications: Member has one of: total blindness in both eyes (nonfunctioning retinas), confirmed Smith‑Magenis syndrome with history of sleep disturbances, or symptoms consistent with Non‑24‑Hour Sleep‑Wake Disorder (difficulty initiating sleep, difficulty awakening, or excessive daytime sleepiness).
If total blindness or Smith‑Magenis syndrome is selected, attach supporting clinical documentation of the diagnosis.
Continuation check: Form asks whether this is a continuation of therapy; if yes, provide date therapy was initiated.
If continuation, also submit clinical documentation of benefit as defined in continuation criteria.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHetlioz (tasimelteon) Prior Authorization — Coverage Criteria

Policy CodePolicy N/A

Change TypeForm/criteria maintenance

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed Hetlioz prior authorization form with required supporting clinical documentation (fax to 1-866-423-0945 or use Cover My Meds).

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Submission Steps and Documentation

Prior Authorization

Prior Authorization Required

Fax the completed prior authorization form to Neighborhood Health Plan of Rhode Island at 1-866-423-0945. For real‑time coverage determination decisions, submit via CoverMyMeds: https://www.covermymeds.com/epa/caremark/. Include all required fields and supporting clinical documentation at time of submission to avoid processing delays.

Fax: 1-866-423-0945
CoverMyMeds portal: https://www.covermymeds.com/epa/caremark/

Denial Risk

Documentation-based Denial Risk

Failure to provide required supporting clinical documentation or to fully complete the checklist and form fields may result in denial of the request.

Missing attachments for total blindness or Smith‑Magenis syndrome triggers denial risk
Incomplete form fields (member ID, dates, prescriber signature) may lead to processing delays or denial

Documentation Required

Form Fields to Submit

Provide complete enrollee and prescription details on the form. Required fields include patient demographics, medication details, diagnosis, and prescriber information.

Enrollee name, DOB, address, phone, member ID
Medication name, strength, route, frequency, quantity
New prescription or date therapy initiated; expected length of therapy
Height/weight; drug allergies; diagnosis
Prescriber name, NPI, office address, phone, fax
Prescriber signature and date

Note

Continuation Check (no explicit step therapy)

If this is a continuation of therapy, indicate that on the form and supply the date therapy was initiated. For continuation requests, include clinical documentation demonstrating treatment response: increased total nighttime sleep or decreased daytime naps for Non‑24, or improved sleep quality metrics for Smith‑Magenis–related sleep disturbances.

Is this for continuation of therapy? — Yes/No (if yes, supply date therapy initiated)
For Non‑24 continuation: submit documentation of increased nighttime sleep and/or decreased daytime naps
For Smith‑Magenis continuation: submit documentation of improved sleep efficiency/onset/offset or reduced awakenings

Criteria for Continuation of Therapy

Continuation criteria

Requirements for renewal/continuation requests.

Continuation evidence: If request indicates continuation of therapy, provide the date therapy was initiated and submit clinical documentation demonstrating benefit.

For Non‑24‑Hour Sleep‑Wake Disorder, documentation should show increased total nighttime sleep and/or decreased daytime nap duration. For sleep disturbances in Smith‑Magenis syndrome, documentation should show improvement in sleep quality measures (e.g., sleep efficiency, sleep onset/offset, or reduced awakenings).

Step Therapy and Related Information

Question	Form response options / required documentation
Is this for continuation of therapy? If yes, supply date therapy initiated
Response options: Yes / No. If Yes, provide prior therapy start date (date therapy initiated) and supporting clinical documentation of clinical response as specified below.
For continuation in Non-24-Hour Sleep‑Wake Disorder: has the member experienced an increase in total nighttime sleep and/or decreased daytime nap duration?
Response options: Yes / No. If Yes, submit clinical documentation demonstrating increased total nighttime sleep and/or decreased daytime napping. If No, absence of documentation may affect approval.
For continuation in Smith‑Magenis syndrome: has the member experienced improvement in sleep quality (e.g., sleep efficiency, sleep onset/final offset, or reduced awakenings)?
Response options: Yes / No. If Yes, submit clinical documentation showing improvement in sleep quality measures. If total blindness or Smith‑Magenis syndrome is indicated, attach supporting clinical documentation of diagnosis as requested elsewhere on the form.

Definitions and Key Terms

Continuation of Therapy — definition and documentation

DefinitionContinuation of therapy: request is for ongoing treatment and requires the date therapy was initiated.

Required documentationAttach clinical documentation demonstrating response to therapy for continuation requests: for Non-24-Hour Sleep-Wake Disorder show increased total nighttime sleep and/or decreased daytime nap duration; for Smith-Magenis syndrome show improvement in sleep quality (e.g., sleep efficiency, sleep onset/final offset, or reduced awakenings).

Form field to completeIf this is for continuation of therapy, complete the form question and supply the date therapy was initiated on the form.

Clinical notesSubmit supporting clinical notes or objective sleep measures that document the described improvements for the specified diagnosis.

Total blindness — definition and required supporting documentation

DefinitionTotal blindness: diagnosis of total blindness in both eyes (e.g., nonfunctioning retinas).

Documentation requirementIf total blindness is indicated on the form, attach supporting clinical documentation of the diagnosis.

Form questionAnswer the questionnaire item asking whether the member has total blindness in both eyes and indicate ability to perceive light if applicable.

Supporting evidence examplesProvide clinical records, ophthalmology notes, or diagnostic testing that confirm nonfunctioning retinas or equivalent documentation of bilateral total blindness.

OpenPayer