sodium oxybate [Xyrem authorized generic (manufactured by Amneal)] — United Healthcare

Initial criteria

• Diagnosis of narcolepsy with cataplexy (i.e., Narcolepsy Type 1) as confirmed by sleep study (unless the prescriber provides justification confirming that a sleep study would not be feasible)
• AND Symptoms of excessive daytime sleepiness (including but not limited to daily periods of irrepressible need to sleep or daytime lapses into sleep) are present
• AND Cataplexy is present

Reauthorization criteria

• Reduction in frequency of cataplexy attacks associated with therapy OR Reduction in symptoms of excessive daytime sleepiness associated with therapy

Approval duration

Initial: 6 months; Reauthorization: 12 months