Xywav (calcium, magnesium, potassium, and sodium oxybates) — CareFirst (Caremark)

Initial criteria

• Member age ≥ 7 years
• Diagnosis of narcolepsy confirmed by a sleep lab evaluation
• Member has a baseline history of at least 3 cataplexy attacks per week
• Medication must be prescribed by or in consultation with a sleep specialist (e.g., neurologist experienced with sleep disorders, physician certified in sleep medicine)

Reauthorization criteria

• Documentation of beneficial response to treatment as defined by a decrease in cataplexy episodes from baseline

Approval duration

12 months