- Prior Authorization: EDS due to OSA:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 year(s)
Narcolepsy Type 1, Narcolepsy Type 2: Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 year(s)
- PA Applies
- EDS due to OSA:
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Narcolepsy Type 1, Narcolepsy Type 2: Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Neurology: Narcolepsy: Age Requirement: >= 18
Duration: 1 year(s)
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
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.: Yes
Patient must have CSF hypocretin 1 deficiency: Yes
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);Narcolepsy Type 2 (without Cataplexy)
Documented Diagnosis: Yes
Patient has >1 Cataplexy Episodes: Yes
Documented Daily EDS occurrences >= 3 months: Yes
MSLT <8min with evidence of 2 SOREMP's: Yes
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: ST Single Generic
- Quantity Limit: 1 tablet per 1 day(s).
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;
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