- Prior Authorization: Prior authorization required. Member should try alternative(s) before submitting a prior authorization. If approved, covered at appropriate tier under the member's pharmacy benefit. Prior authorization required age 30 and up.
- Prior Authorization: Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 12 Month(s)
Reauthorization Required: Yes
- Idiopathic Hypersomnia:
Age Requirement: >= 18
Duration: 3 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Narcolepsy Type 1, Narcolepsy Type 2:
Age Requirement: >= 7
Duration: 3 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Neurology: Narcolepsy:
Age Requirement: >= 7
Duration: 3 Month(s)
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
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: Yes
Patient Does Not Have a History of Substance Abuse: No
Patient is Not Using a Sedative Hypnotic: Yes
Patient Will Not Be Using with Alcohol: Yes
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 Narcolepsy Type 1 (with Cataplexy);Narcolepsy Type 2 (without Cataplexy)
Supporting Documentation Requirements: 2 of Chart Notes;Medical Tests;Medication History
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
- Cluster Seizure/Seizure Emergency:
Age Requirement: >= 6
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
|