Does Medicare Cover Xyrem? | Medicare & Medicare Advantage Info, Help and Enrollment

The generic name for Xyrem is sodium oxybate and is prescribed for narcolepsy, which is a chronic sleep disorder. People with narcolepsy are prone to cataplexy that manifests as abrupt and short attacks of weakened or paralyzed muscles. The function of sodium oxybate is to reduce the sleepiness during daytime hours. It also serves to lessen the episodes associated with cataplexy. The U.S. Food and Drug Administration refers to the treatment of cataplexy as an orphan disease designation.

Risks of Xyrem

A Risk Evaluation and Mitigation Strategy (REMS) is a government drug safety program developed to lower the severity and/or occurrence of particular risks by driving safe-use conditions. The program is a requirement for prescription drugs that pose serious safety concerns. Sodium oxybate is only available through the REMS program because of the potential risk of central nervous system depression, abuse and improper use. Both Xyrem and its generic alternative are subject to the same REMS requirements. According to the FDA, the prescriber must not only screen, counsel and evaluate individuals who are prescribed the drug, but they are also mandated to report adverse events. Additionally, pharmacies that dispense the drug have been certified in the REMS program.

Medicare Drug Coverage

Medicare benefits for drugs will vary with your insurance carrier, the plan in which you are enrolled. Part D represents the pharmaceutical drug portion of Medicare benefits. However, it is optional and available only through a Medicare-approved private insurance company. Some Medicare recipients choose Original Medicare, with or without a supplemental plan, for Parts A and B, and also enroll in a stand-alone plan for Part D. Others sign up for an all-inclusive Medicare Advantage plan including Parts A, B and D. Most insurance companies make their drug formulary easily accessible online. When you go to the plan’s website, it should be as easy as entering your zip code, clicking the respective plan and typing the drug name in the search field to check for coverage.

Diagnosis of narcolepsy

Before Xyrem is prescribed, your doctor will most likely recommend further evaluation, which may entail a referral to a sleep center. Sleep specialists would analyze your sleep history and sleep patterns. They may also perform a series of tests that measure a range of sleep signals and the time it takes for you to fall asleep in the daytime. Conducting these analyses and tests not only facilitate a formal diagnosis but serve to rule out other potential reasons for the symptoms experienced.

Before taking any medication, be sure your medical practitioner has a record of all prescription and over-the-counter medications you are taking as well as any chemical and natural supplements. Sharing this information is the best way to avoid drug contraindications and help your healthcare provider determine the best approach to treat your condition.

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