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NYS Medicaid Pharmacy Programs

sodium oxybate (Xyrem®)

sodium oxybate (Xyrem®)

Prior Authorization Call Line: 1-877-309-9493

Prior authorization for sodium oxybate (Xyrem®) is required to assure medical necessity and to deter the potential of, or history of, drug diversion or illegal utilization. Only prescribers, not their authorized agents, can complete the prior authorization process for Xyrem®.

Prior authorization requirements:

  • Prescribers are required to call the toll free telephone number 1-877-309-9493 and respond to a series of questions that identify the prescriber, the patient and the reason for prescribing this drug.
  • Please be prepared to fax validating documentation for each request.
  • Initial prior authorizations will be limited to a maximum of a one-month supply. Subsequent prior authorizations will be limited to two refills.
  • If a patient has received a prior authorization for Xyrem® recently, the prescriber will be informed of that issuance date. A new prior authorization for Xyrem® will not be issued unless 75% of the previously authorized product has been used as determined by the previous issuance date.