CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Sodium oxybate (Xyrem/Lumryz) for narcolepsy (EDS and cataplexy)

Covers prior authorization, clinical criteria, and documentation requirements for sodium oxybate products (Xyrem, Lumryz) used to treat cataplexy or excessive daytime sleepiness (EDS) in patients with narcolepsy for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySodium oxybate (Xyrem/Lumryz) for narcolepsy (EDS and cataplexy)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for up to 12 months when specified clinical criteria are met and provide required documentation including sleep lab confirmation and prior therapy history.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization duration

>=7minimum age

>=3/weekcataplexy threshold

Requiredsleep lab

Coverage Criteria for Sodium Oxybate

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

EDS (Initial therapy)

Authorization of 12 months may be granted for treatment of excessive daytime sleepiness (EDS) with narcolepsy when ALL of the following are met:

EDS (Initial therapy): (1) Diagnosis of narcolepsy is confirmed by a sleep lab evaluation; AND (2) Member meets one of the following age‑specific prior therapy requirements: For members 7 to <18 years: inadequate treatment response or intolerance to at least one CNS stimulant (e.g., amphetamine, dextroamphetamine, methylphenidate) OR contraindication to at least one CNS stimulant; For members >=18 years: inadequate treatment response or intolerance to modafinil or armodafinil OR contraindication to both modafinil and armodafinil.

Authorization period = 12 months

EDS (Continuation therapy)

Authorization of 12 months may be granted for continued treatment of EDS when ALL of the following are met:

EDS (Continuation therapy): Member has demonstrated beneficial response to treatment as defined by a decrease in daytime sleepiness from baseline.

Authorization period = 12 months

Cataplexy (Initial therapy)

Authorization of 12 months may be granted for treatment of cataplexy with narcolepsy when ALL of the following are met:

Cataplexy (Initial therapy): (1) Member is 7 years of age or older; AND (2) Diagnosis of narcolepsy is confirmed by a sleep lab evaluation; AND (3) Member has a baseline history of at least 3 cataplexy attacks per week.>= 3 cataplexy attacks/week

Authorization period = 12 months

Cataplexy (Continuation therapy)

Authorization of 12 months may be granted for continued treatment of cataplexy when ALL of the following are met:

Cataplexy (Continuation therapy): Member has demonstrated beneficial response to treatment as defined by a decrease in cataplexy episodes from baseline.

Authorization period = 12 months

Prior Authorization, Documentation, and Administrative Notes

Prior Authorization

Prior authorization duration and general rule

Authorization of 12 months may be granted for treatment of excessive daytime sleepiness (EDS) or cataplexy in narcolepsy when specified clinical criteria are met (see medical necessity criteria).

Prior authorization duration: up to 12 months when criteria for EDS or cataplexy in narcolepsy are met.

Documentation Required

Required documentation

For initial requests, submit documentation of a sleep lab evaluation and chart notes/medical records or claims history supporting prior medications tried and response to therapy (or clinical reasons to avoid those therapies). For continuation requests, submit chart notes demonstrating a beneficial response to therapy: decreased daytime sleepiness for EDS or decreased cataplexy episodes for cataplexy.

Initial requests: sleep lab evaluation; chart notes/medical records or claims history showing prior medications tried and response, or reasons to avoid therapy.
Continuation requests: documentation of clinical benefit (reduced daytime sleepiness for EDS or reduced cataplexy frequency for cataplexy).

Denial Risk

Non‑covered indications

All indications other than treatment of cataplexy or excessive daytime sleepiness (EDS) in patients 7 years of age and older with narcolepsy are considered experimental/investigational and not medically necessary.

Non‑covered indications: any use beyond cataplexy or EDS in patients ≥7 years with narcolepsy.

Step Therapy

Step therapy note

Per regulatory guidelines around behavioral health, step therapy restrictions may vary by jurisdiction and regulatory requirements — check applicable state/regulatory rules when applying step therapy prior to authorization.

Step therapy note: Step therapy requirements may be modified or restricted by behavioral health regulations; verify state-specific rules before denying/requiring step edits.

Key Definitions and FDA‑approved Indication

FDA‑approved indication — inv-12

IndicationTreatment of cataplexy or excessive daytime sleepiness (EDS) in patients 7 years of age and older with narcolepsy.

Minimum patient age7 years of age and older

ScopeApplies only to narcolepsy-related cataplexy or EDS; other indications are experimental/investigational and not medically necessary.

Products coveredSodium oxybate preparations (e.g., Xyrem, Lumryz) when used for the FDA‑approved indication above.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySodium oxybate (Xyrem/Lumryz) for narcolepsy (EDS and cataplexy)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for up to 12 months when specified clinical criteria are met and provide required documentation including sleep lab confirmation and prior therapy history.

SourceLink

On This Page

OpenPayer

Sodium oxybate (Xyrem/Lumryz) for narcolepsy (EDS and cataplexy)

Coverage Criteria for Sodium Oxybate

Prior Authorization, Documentation, and Administrative Notes

Key Definitions and FDA‑approved Indication

Background