- Prior Authorization: Narcolepsy Type 1, Narcolepsy Type 2:
Documented Diagnosis: Yes
Duration: 1 year(s)
Neurology: Narcolepsy:
PA Applies
- Available only through Specialty Pharmacy; Dose Optimization- 2 tablets per day
For details on drug coverage click HERE;
- Step Therapy: Narcolepsy Type 1, Narcolepsy Type 2:
ST Multiple Generics
Neurology: Narcolepsy:
Step Applies
- Narcolepsy Type 1, Narcolepsy Type 2:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Neurology: Narcolepsy:
Duration: 1 year(s)
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
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
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
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