- Available through Specialty Pharmacy;
- Idiopathic Hypersomnia, Narcolepsy Type 1, Narcolepsy Type 2:
Duration: 3 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Neurologist;Psychiatrist;Pulmonologist;Sleep Disorders Specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Neurology: Narcolepsy:
Duration: 3 Month(s)
Specialist Required: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Neurologist;Psychiatrist;Pulmonologist;Sleep Disorders Specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Number of Episodes of Cataplexy Required in Policy: Unspecified
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, 15 min from preceding night polysomnography (PSG)
Other causes of sleepiness have been ruled out.: Yes
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 Narcolepsy Type 1 (with Cataplexy);Narcolepsy Type 2 (without Cataplexy)
Supporting Documentation Requirements: 3 of Chart Notes;Diagnosis confirmed by sleep lab evaluation;Medical Tests
Documented Diagnosis: Yes
Patient has >1 Cataplexy Episodes: No
Documented Daily EDS occurrences >= 3 months: Yes
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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