Medicare AdvantagePrior AuthMedium impact
Xyrem® (sodium oxybate) (Revised)
Humana·Neurology, Sleep Medicine, Pharmacy·Medicare Advantage
Effective date
Jan 1, 2025
We identified it
Jun 25, 2026
Summary
This is a revised Humana Medicare Advantage prior authorization policy for Xyrem® (sodium oxybate) effective January 1, 2025, with updates through March 25, 2026. The policy establishes coverage criteria for two narcolepsy indications: narcolepsy with cataplexy and narcolepsy with excessive daytime sleepiness (EDS). Key requirements include documented diagnosis, previous treatment/intolerance to generic sodium oxybate for brand requests, and exclusivity (no concurrent use with related medications). Billing teams must ensure prior authorization is obtained before claims are submitted, and providers must document clinical criteria met.
Action Required
By January 1, 2025, the billing and prior authorization teams must: (1) Update billing system to flag all Xyrem® (sodium oxybate) and generic sodium oxybate claims for mandatory prior authorization under Humana Medicare Advantage plans; (2) Ensure prior authorization requests include documentation of narcolepsy diagnosis per ICSD-3 or DSM-5 criteria, previous treatment/intolerance to generic sodium oxybate for brand requests, and confirmation that member is not concurrently using Xywav, Lumryz, Wakix, or Sunosi; (3) For EDS-only indications, require documented sleep testing (polysomnography or MSLT) and failed trial of CNS stimulant or modafinil/armodafinil; (4) Update prior authorization submission forms and encounter templates to capture these requirements; (5) Train billing staff to verify all criteria are met before submission to avoid denials. Failure to obtain prior authorization will result in claim denials from Humana Medicare Advantage.