Kaiser Foundation Health Plan Southern California |
Xywav (sodium,calcium,mag,pot oxybate) |
Drugs for the Nervous System : Drugs for Sleep Disorder |
- Idiopathic Hypersomnia, Narcolepsy Type 1, Narcolepsy Type 2:
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Sleep Disorders Specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Neurology: Narcolepsy: Duration: 12 Month(s)
Specialist Required: Yes
Medical Test Required: No
Specialist Type(s): Sleep Disorders Specialist
Reauthorization Required: No
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): 1 of Excessive daytime sleepiness associated with narcolepsy;Narcolepsy Type 1 (with Cataplexy)
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
Duration: 12 Month(s)
Reauthorization Required: Yes
- Step Therapy: Narcolepsy Type 1:
ST Generic and Brand
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