| Anthem Blue Cross (HMO, PPO, EPO) |
| Xywav (sodium,calcium,mag,pot oxybate) |
| Drugs for the Nervous System : Drugs for Sleep Disorder |
- Idiopathic Hypersomnia:
Age Requirement: >= 18
Duration: 3 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Narcolepsy Type 1, Narcolepsy Type 2:
Age Requirement: >= 7
Duration: 3 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Neurology: Narcolepsy:
Age Requirement: >= 7
Duration: 3 Month(s)
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Number of Episodes of Cataplexy Required in Policy: > 1
Documented Duration of Daily EDS Occurrences: >= 3 month(s)
Policy Criteria Required to Document Patient Multiple Sleep Latency Test (MSLT): 1 of MSLT =< 8 min with evidence of >=2 SOREMPs;MSLT with evidence of >= 1 SOREMP's and SOREMP, 15 min from preceding night polysomnography (PSG)
Other causes of sleepiness have been ruled out.: No
Patient must have CSF hypocretin 1 deficiency: Yes
Patient Does Not Have a Deficiency of Succinic Semialdehyde Dehydrogenase: Yes
Patient Does Not Have a History of Substance Abuse: No
Patient is Not Using a Sedative Hypnotic: Yes
Patient Will Not Be Using with Alcohol: Yes
Documentation Requiring Patient to be Enrolled in REMS Success Program: No
Documentation of prescriber enrollment in REMS program: No
Prescriber Must Check Patient's Drug History on Controlled Substance Database: No
Documented Time Period or Frequency of Time That the Precriber Must Regularly See the Patient: N/A
Diagnosis Type(s): 1 of Narcolepsy Type 1 (with Cataplexy);Narcolepsy Type 2 (without Cataplexy)
Supporting Documentation Requirements: 2 of Chart Notes;Medical Tests;Medication History
Documented Diagnosis: Yes
Patient has >1 Cataplexy Episodes: Yes
Documented Daily EDS occurrences >= 3 months: Yes
MSLT <8min with evidence of 2 SOREMP's: No
MSLT with evidence of >= 1 SOREMP's and SOREMP, 15 min from preceeding night PSG: Yes
CSF Hypocretin-1 Deficiency: Yes
Prescriber Must See Patient Every 3 Months: No
- Step Therapy: Narcolepsy Type 1:
ST Multiple Brands
- Quantity Limit: limit maximum 18 mL PER 1 day(s)
- Prior Authorization: Idiopathic Hypersomnia:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 3 Month(s)
Reauthorization Required: Yes
Narcolepsy Type 1, Narcolepsy Type 2:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 7
Duration: 3 Month(s)
Reauthorization Required: Yes
- PA Applies
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
|