Xyrem — Blue Cross Blue Shield of Oklahoma

Preferred products

• Authorized generic Sodium Oxybate

Initial criteria

• If request for brand Xyrem, ONE of the following:
• Patient currently stable on requested agent OR
• Tried authorized generic Sodium Oxybate with inadequate response or discontinued due to adverse event/intolerance/contraindication OR
• Authorized generic Sodium Oxybate expected ineffective, not in best interest, worsens comorbid condition, causes barriers, or harm OR
• Patient has tried another drug in same pharmacologic class/mechanism as authorized generic Sodium Oxybate and discontinued due to ineffectiveness or side effects OR
• There is support for use over authorized generic Sodium Oxybate
• Prescriber must be specialist or consult specialist
• No FDA labeled contraindications

Reauthorization criteria

• 1. Patient previously approved for Xyrem through plan PA process AND
• 2. Prescriber is or consulted with relevant specialist AND
• 3. Patient shows clinical benefit AND
• 4. No contraindications

Approval duration

12 months