- EDS due to OSA, Narcolepsy Type 1, Narcolepsy Type 2:
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Neurology: Narcolepsy: Duration: 6 Month(s)
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Number of Episodes of Cataplexy Required in Policy: N/A
Documented Duration of Daily EDS Occurrences: N/A
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): Unspecified
Supporting Documentation Requirements: Diagnosis confirmed by sleep lab evaluation
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: Erectile Dysfunction (ED):
Duration: 1 year(s)
- Split Fill;
- Chronic Lymphocytic Leukemia:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: Payer Specific
Diagnosis Types: 1 of Chronic Lymphocytic Leukemia;Small Lymphocytic Lymphoma
Multiple Myeloma: Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: NCCN Guidelines
ECOG Score Requirement in Policy: N/A
ECOG status <=2: No
Diagnosis Types: 2 of Multiple Myeloma;Progressive disease;Relapsed disease
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