- ST Required
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;- Quantity Limit: 35 grams per 30 day(s).
- ST_APPLIES
- ST_APPLIES
- Narcolepsy Type 1:
Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Neurologist;Sleep Disorders Specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Narcolepsy Type 2:
Age Requirement: >= 18
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: >= 18
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: N/A
Documented Duration of Daily EDS Occurrences: N/A
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: 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)
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: Yes
Prescriber Must See Patient Every 3 Months: No
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