Xywav (calcium, magnesium, potassium, and sodium oxybates) — CareFirst (Caremark)
Excessive daytime sleepiness (EDS) with narcolepsy
Preferred products
- armodafinil
- modafinil
- amphetamine
- dextroamphetamine
- methylphenidate
Initial criteria
- Diagnosis of narcolepsy confirmed by a sleep lab evaluation
- Member age 7–<18 years: inadequate treatment response, intolerance, or contraindication to at least one central nervous system stimulant drug (e.g., amphetamine, dextroamphetamine, methylphenidate)
- Member age ≥ 18 years: inadequate treatment response, intolerance, or contraindication to both armodafinil and modafinil
- 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
- Beneficial response to treatment as demonstrated by a decrease in daytime sleepiness with narcolepsy from baseline
Approval duration
12 months