Medicare AdvantagePrior AuthMedium impact
Wakix® (pitolisant) (Revised)
Humana·Neurology, Sleep Medicine, Psychiatry·Medicare Advantage
Effective date
Jan 1, 2025
We identified it
Jun 25, 2026
Summary
Humana has revised its Wakix® (pitolisant) prior authorization policy for Medicare Advantage members, effective January 1, 2025, with the most recent revision dated February 25, 2026. The policy establishes specific clinical criteria for coverage of Wakix for two indications: excessive daytime sleepiness (EDS) with narcolepsy and cataplexy with narcolepsy. Key requirements include documented narcolepsy diagnosis per ICSD-3/DSM-5, sleep testing confirmation, no QT prolongation risk factors, prior treatment failure with CNS stimulants and modafinil/armodafinil, and restriction to one competing medication at a time. Prior authorization is required for all Wakix requests.
Action Required
By January 1, 2025: Billing team and clinical staff must implement prior authorization requirements for all Wakix (pitolisant) requests for Medicare Advantage members. Create internal checklist to verify the five clinical criteria before submitting PA requests: (1) narcolepsy diagnosis documentation per ICSD-3 or DSM-5, (2) sleep testing results (polysomnography or MSLT), (3) absence of QT prolongation risk factors, (4) documented treatment history with CNS stimulants AND modafinil/armodafinil (with contraindication or intolerance noted), and (5) verification member is not concurrently using Xyrem, Xywav, Lumryz, or Sunosi. For cataplexy indication, verify only criteria 1 and 5 apply. Route all PA requests through Humana PAL system at www.humana.com/PAL. Update encounter forms and EMR templates to prompt providers to document sleep testing results and prior medication trials. Do not process claims without documented prior authorization approval. Claims submitted without meeting criteria or proper PA will be denied.