Medicare AdvantagePrior AuthHigh impact
Lumryz (sodium oxybate) (Revised)
Humana·Neurology, Sleep Medicine, Internal Medicine·Medicare Advantage
Effective date
Jul 26, 2023
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage updated its Lumryz (sodium oxybate) prior authorization policy effective July 26, 2023, with a revision dated July 24, 2024. The policy maintains two distinct approval pathways: (1) Narcolepsy with cataplexy requires diagnosis confirmation and exclusivity of competing narcolepsy agents, with 3-month initial and 6-month renewal approvals; (2) Narcolepsy with excessive daytime sleepiness requires documented sleep testing and prerequisite trial/intolerance of CNS stimulants and modafinil before approval. The billing team must ensure all Lumryz requests include proper prior authorization before claim submission, as this is a controlled substance requiring enrollment in the Lumryz REMS Program.
Action Required
By July 26, 2024 (revision effective date): (1) Billing team must update prior authorization workflow in billing system to require documented diagnosis of narcolepsy with cataplexy OR narcolepsy with excessive daytime sleepiness (ICSD-3 or DSM-5 criteria) for all Lumryz requests. (2) For EDS cases, verify documentation of sleep testing (polysomnography or multiple sleep latency test) and prior trial/failure/intolerance of at least one CNS stimulant AND modafinil before submitting to Humana for approval. (3) Verify member is not currently using Xyrem, Xywav, Wakix, or Sunosi concurrently—only one narcolepsy agent permitted. (4) Configure system to auto-populate initial approval duration as 3 months and renewal duration as 6 months. (5) Front desk and providers must confirm patient/prescriber enrollment in Lumryz REMS Program before claim processing. (6) Update prior authorization request templates to capture cataplexy frequency reduction (for cataplexy indication) or EDS symptom reduction (for EDS indication) for renewal requests. Claims submitted without proper prior authorization or missing required documentation will be denied by Humana.