Xyrem (Sodium Oxybate) Prior Authorization Of Benefits (Pab) Form Page 2
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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
PATIENT NAME: _________________________________________ PATIENT ID #: ______________________________
Initial Requests for Diagnosis of Narcolepsy 2 (narcolepsy without cataplexy) (Continued):
□
□
Yes
No
Patient has had a previous trial of and inadequate response or intolerance to methylphenidate,
dextroamphetamine, or amphetamine/dextroamphetamine salt immediate-release
□
□
Yes
No
Trials of wakefulness promoting agents and stimulant agents are unacceptable due to concomitant
clinical situations including but not limited to the following: cardiovascular disease or drug
interactions
□
□
Yes
No
Patient is 18 years of age or older
Renewal Requests:
□
□
Yes
No
Xyrem (sodium oxybate) use has resulted in a reduction in frequency of cataplexy attacks
□
□
Yes
No
Xyrem (sodium oxybate) use has resulted in excessive daytime sleepiness (EDS) as measured by
improvement in Epworth Sleepiness Scale (ESS) measurements or Maintenance of Wakefulness
Test (MWT)
Required Information for ALL Requests:
□
□
Yes
No
Xyrem (sodium oxybate) is being used in combination with other sedative hypnotic agents
□
□
Yes
No
Xyrem (sodium oxybate) is being used in combination with alcohol
□
□
Yes
No
Patient has been diagnosed with succinic semialdehyde dehydrogenase deficiency
9. PHYSICIAN SIGNATURE
____________________________________________________________
__________________________________________
Prescriber or Authorized Signature
Date
Prior Authorization of Benefits is not the practice of medicine or the substitute for the independent medical judgment of a treating physician. Only a treating physician can determine what
medications are appropriate for a patient. Please refer to the applicable plan for the detailed information regarding benefits, conditions, limitations, and exclusions. The submitting
provider certifies that the information provided is true, accurate, and complete and the requested services are medically indicated and necessary to the health of the patient.
Note: Payment is subject to member eligibility. Authorization does not guarantee payment.
The document(s) accompanying this transmission may contain confidential health information that is legally privileged. This information is intended only
for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other
party unless required to do so by law or regulation.
If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of
these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately and arrange for the return or
destruction of these documents.
PAGE 2 OF 2
Xyrem NTL PAB Fax Form 11.09.15.doc
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