Pharmacy: New Review Process for Prescription Drugs Korlym and Xyrem

May 4, 2018

Pharmacy: New Review Process for Prescription Drugs Korlym and Xyrem

Effective July 1, 2018, BlueCross® BlueShield® of South Carolina and BlueChoice Healthplan will conduct all utilization reviews for prescribed drugs Korlym and Xyrem. Reviews for these drugs were previously conducted by CVS Caremark, our Pharmacy Benefit Manager (PBM) partner. This change applies to members of all BlueCross and BlueChoice commercial and Affordable Care Act plans.

To initiate the review process for Korlym and Xyrem, please call the precertification number on the back of the member’s identification card. All requests should be submitted with the required supporting documentation below:

Drug Name: 

Xyrem 

Korlym 

Covered Indication: 

Narcolepsy with cataplexy 

Endogenous (primary) Cushing's syndrome 

Documentation Required for Review:

1. Multiple Sleep Latency Test (MSLT) confirming diagnosis of narcolepsy and chart notes documenting cataplexy.

2. Polysomnography and MSLT confirming diagnosis of excessive daytime sleepiness associated with narcolepsy.

3. Documentation of prior treatment failures, history of daytime lapses into sleep and mean sleep latency.

4. Documentation that other causes of sleepiness have been ruled out. 

1. Response to therapy, including AIC lab results (for continuation of therapy requests). 

2. Initial requests will require documentation of surgical history and response. 

3. If the member is not a surgical candidate, documentation of previous medication therapy failures is required including doses and dates of all drugs tried to date, and laboratory tests (including dates obtained) of serum and urinary cortisol levels to assess efficacy of the previous regimens.

NOTE: Additional supporting clinical documentation may be required to render a decision.

If you have questions about this bulletin, you may contact Provider Education at 803-264-4730 or submit your questions using the Provider Education Contact Form

BlueChoice® HealthPlan of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.