- Step Therapy: Narcolepsy Type 1:
ST Generic and Brand
Narcolepsy Type 2:
ST Multiple Brands
- 1. FDA Approved Indications: a. For the treatment of cataplexy in narcolepsy. b. For the treatment of excessive daytime sleepiness (EDS) in narcolepsy. 2. Health Net Approved Indications and Usage Guidelines: a. Patient must have excessive daytime sleepiness or cataplexy as a symptom associated with narcolepsy. 3. Coverage is Not Authorized For: a. Fibromyalgia. b. Use in combination with sedative hypnotics or alcohol. c. Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature. 4. General Information: a. Per FDA, the Central Pharmacy is allowed to deliver up to a 90 day medication supply at a time. 5. Authorization Limit: Length of benefit.
- Narcolepsy Type 1, Narcolepsy Type 2:
Age Requirement: >= 7
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Neurologist;Sleep Disorders Specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Neurology: Narcolepsy:
Age Requirement: >= 7
Duration: 12 Month(s)
Specialist Required: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Neurologist;Sleep Disorders Specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Number of Episodes of Cataplexy Required in Policy: Unspecified
Documented Duration of Daily EDS Occurrences: Unspecified
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, 15 min from preceding night polysomnography (PSG)
Other causes of sleepiness have been ruled out.: No
Patient must have CSF hypocretin 1 deficiency: No
Patient Does Not Have a Deficiency of Succinic Semialdehyde Dehydrogenase: No
Patient Does Not Have a History of Substance Abuse: No
Patient is Not Using a Sedative Hypnotic: No
Patient Will Not Be Using with Alcohol: No
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 Excessive daytime sleepiness associated with narcolepsy;Narcolepsy Type 1 (with Cataplexy)
Supporting Documentation Requirements: 2 of Chart Notes;Medication History;Polysomnography
Documented Diagnosis: Yes
Patient has >1 Cataplexy Episodes: No
Documented Daily EDS occurrences >= 3 months: No
MSLT <8min with evidence of 2 SOREMP's: No
MSLT with evidence of >= 1 SOREMP's and SOREMP, 15 min from preceeding night PSG: No
CSF Hypocretin-1 Deficiency: No
Prescriber Must See Patient Every 3 Months: No
- Prior Authorization: Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 7
Duration: 12 Month(s)
Reauthorization Required: Yes
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