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Xyrem — Blue Cross Blue Shield of Alabama

idiopathic hypersomnia

Preferred products

  • authorized generic Sodium Oxybate

Initial criteria

  • ONE of the following:
  • • The patient has a diagnosis of narcolepsy with cataplexy OR narcolepsy with excessive daytime sleepiness AND ONE of the following:
  • – The patient has tried and had an inadequate response to modafinil OR armodafinil OR
  • – The patient has an intolerance or hypersensitivity to modafinil OR armodafinil OR
  • – The patient has an FDA labeled contraindication to BOTH modafinil AND armodafinil
  • OR
  • • The patient has a diagnosis of idiopathic hypersomnia AND ALL of the following:
  • – The requested agent is Xywav AND
  • – The patient has completed a sleep study AND
  • – All other causes of hypersomnia have been ruled out AND
  • – ONE of the following:
  • ▪ The patient has tried and had an inadequate response to modafinil OR
  • ▪ The patient has an intolerance or hypersensitivity to modafinil OR
  • ▪ The patient has an FDA labeled contraindication to modafinil
  • OR
  • • The patient has another FDA labeled indication for the requested agent and route of administration
  • AND
  • If the patient has an FDA approved indication, ONE of the following:
  • – The patient’s age is within FDA labeling for the requested indication for the requested agent OR
  • – The prescriber has provided information in support of using the requested agent for the patient’s age for the requested indication
  • AND
  • If the request is for brand Xyrem, then ONE of the following:
  • – The patient has an intolerance or hypersensitivity to authorized generic Sodium Oxybate that is not expected to occur with the requested agent OR
  • – The patient has an FDA labeled contraindication to authorized generic Sodium Oxybate that is not expected to occur with the requested agent OR
  • – There is support for the use of the requested agent over authorized generic Sodium Oxybate
  • AND
  • The patient will NOT be using the requested agent in combination with another oxybate agent, Sunosi, OR Wakix for the requested indication
  • AND
  • The prescriber is a specialist in the area of the patient’s diagnosis (e.g., sleep specialist, neurologist, psychiatrist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
  • AND
  • The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months