Xyrem (Sodium Oxybate) Prior Authorization Of Benefits (Pab) Form
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1
2CONTAINS CONFIDENTIAL PATIENT INFORMATION
Xyrem (sodium oxybate)
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
1. PATIENT INFORMATION
2. PHYSICIAN INFORMATION
Patient Name: __________________________________
Prescribing Physician: ____________________________
Patient ID #:
__________________________________
Physician Address:
_____________________________
Patient DOB: __________________________________
Physician Phone #:
_____________________________
Date of Rx:
__________________________________
Physician Fax #:
_____________________________
Patient Phone #: _______________________________
Physician Specialty:
____________________________
Patient Email Address: ___________________________
Physician DEA:
____________________________
Physician NPI #:
_____________________________
Physician Email Address: ___________________________
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
________________
Xyrem (sodium oxybate)
______________________
Specify: _________________
7. DIAGNOSIS: ___________________________________________________________________________________
CHECK ALL BOXES THAT APPLY
8. APPROVAL CRITERIA:
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.
Initial Requests for Diagnosis of Narcolepsy Type 1 (narcolepsy with cataplexy):
□
□
Yes
No
Patient has a diagnosis of Narcolepsy Type 1 (narcolepsy with cataplexy)
□
□
Patient’s diagnosis has been confirmed by the presence of daily periods of irrepressible need to
Yes
No
sleep or daytime lapses into sleep occurring for at least 3 months
□
□
Patient has clear cataplexy (defined as “more than one episode of generally brief [less than 2
Yes
No
minutes] usually bilaterally symmetrical, sudden loss of muscle tone with retained consciousness”)
□
□
Yes
No
Multiple sleep latency test (MSLT) shows a mean sleep latency of less than 8 minutes with evidence
of two sleep-onset rapid eye movement periods (SOREMPs)
□
□
Yes
No
Multiple sleep latency test (MSLT) shows at least one SOREMP on MSLT and a SOREMP (less than
15 minutes) on the preceding overnight polysomnography (PSG)
□
□
Yes
No
Patient has cerebrospinal fluid hypocretin-1 deficiency (less than [<] 110 pg/mL or less than one-third
of the normative values with the same standardized assay)
□
□
Yes
No
Patient is 18 years of age or older
Initial Requests for Diagnosis of Narcolepsy Type 2 (narcolepsy without cataplexy):
□
□
Yes
No
Patient has a diagnosis of Narcolepsy Type 2 (narcolepsy without cataplexy)
□
□
Patient’s diagnosis has been confirmed by daily periods of irrepressible need to sleep or daytime
Yes
No
lapses into sleep occurring for at least 3 months
□
□
Yes
No
Multiple sleep latency test (MSLT) shows a mean sleep latency of less than 8 minutes with evidence
of two sleep-onset rapid eye movement periods (SOREMPs)
□
□
Yes
No
Multiple sleep latency test (MSLT) shows at least one SOREMP on MSLT and a SOREMP (less than
15 minutes) on the preceding overnight polysomnography (PSG)
□
□
Patient’s diagnosis has been confirmed by the absence of cataplexy
Yes
No
□
□
Patient’s diagnosis has been confirmed by exclusion of alternative causes of excessive daytime
Yes
No
sleepiness by history, physical exam and polysomnography
□
□
Yes
No
Patient has had a previous trial of and inadequate response or intolerance to Modafinil or Nuvigil
(armodafinil)
PAGE 1 OF 2 – CONTINUED ON PAGE 2
Xyrem NTL PAB Fax Form 11.09.15.doc
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