Medicare AdvantagePrior AuthMedium impact
Xywav® (calcium, magnesium, potassium, and sodium oxybates) (Revised)
Humana·Neurology, Sleep Medicine, Internal Medicine·Medicare Advantage
Effective date
Jan 1, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has updated its prior authorization policy for Xywav® (calcium, magnesium, potassium, and sodium oxybates), effective January 1, 2025. The policy covers three indications: narcolepsy with cataplexy, narcolepsy with excessive daytime sleepiness, and idiopathic hypersomnia. All three indications now require prior authorization with specific clinical criteria, including prior sodium oxybate treatment and documentation of diagnostic testing. Claims must also demonstrate the member is using only one competing product at a time.
Action Required
By January 1, 2025: Billing team must implement prior authorization requirements for all Xywav® pharmacy claims submitted to Humana Medicare Advantage plans. Create a pre-authorization checklist requiring: (1) diagnosis confirmation (narcolepsy with cataplexy, narcolepsy with EDS, or idiopathic hypersomnia per ICSD-3 or DSM-5), (2) documentation of prior sodium oxybate treatment, (3) for EDS and IH cases: documented sleep testing results (polysomnography or MSAT) and evidence of prior CNS stimulant or modafinil/armodafinil treatment or contraindication/intolerance, and (4) verification that member is not concurrently using Xyrem, Lumryz, Wakix, or Sunosi. Front desk staff must collect this documentation before claim submission. Providers must document all required clinical criteria in encounter notes. Update billing software rules to flag Xywav® claims as requiring prior auth. Verify member plan type is Humana Medicare Advantage before applying this policy. Claims submitted without prior authorization will be denied.