Xyrem (sodium oxybate) — Point32Health
excessive daytime sleepiness associated with narcolepsy
Initial criteria
- Patient age ≥ 7 years
- Prescribed by or in consultation with a neurologist or sleep specialist
- Documentation that patient is not concurrently taking a sedative hypnotic OR provider attests all hypnotic agents discontinued before initiating treatment
- EITHER documented diagnosis of narcolepsy with cataplexy OR (documented diagnosis of excessive daytime sleepiness associated with narcolepsy AND for age ≥18 years: inadequate response, adverse reaction, or contraindication to ALL of modafinil OR armodafinil, stimulant medication, and Sunosi OR for age 7–17 years: trial and failure, inadequate response, intolerance, or contraindication to one stimulant medication) OR (request is for Xywav and patient has documented diagnosis of idiopathic hypersomnia)
Reauthorization criteria
- Documentation that patient had an office visit and was reassessed for the condition within the past year and continued therapy continues to be considered medically necessary
- Patient is not concurrently using a sedative hypnotic as evidenced by claims history within the past 90 days
Approval duration
12 months