DAYVIGO (lemborexant)

SELF-ADMINISTRATION

Indications for Prior Authorization:
  • Indicated for the treatment of adult patients with insomnia, characterized by difficulties with sleep onset and/or sleep maintenance
Patients must meet the following criteria for the indication(s) above:
  • Diagnosis of insomnia, AND
  • For patients < 65 years old:  has tried and failed two preferred medications (e.g., estazolam, eszopiclone, ramelteon, temazepam, zaleplon, zolpidem) as confirmed by medical record documentation and/or prescription claims history.
Dosing:
  • 5 mg once daily at bedtime with at least 7 hours before planned time of awakening
  • Max: 10 mg once daily
Authorization is Not Covered for the Following:
  • The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics Committee.
Approval:
  • 1 year
Review History:
  • 8/1/20- Original review
References:
  • DayVigo Prescribing Information. Eisai Inc. Woodcliff Lake, NJ. December 2019.  

 

Last review date: January 29, 2021

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