HealthNet - All plan years
Xyrem (sodium oxybate)
Drugs for the Nervous System : Drugs for Sleep Disorder
  • Prior Authorization: PA_APPLIES
  • Prior Authorization: Breast Cancer: HR+ (HER2+):
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Duration: 1 year(s)

  • Psoriasis (PsO):
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 24 month(s)
    TB Test required: No
    History of Plaque Psoriasis: N/A
    Overall % of Body Surface For Initiation: 5
    Overall % of Body Surface For Initiation With Sensitive Areas: Unspecified
    Psoriasis Classification: Moderate-Severe
    Sensitive Area BSA Percent override: Yes

  • Quantity Limit: 3 capsules per 1 day(s).
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