By Counterforce Health Team in Xyrem (sodium oxybate) —

How to Get Xyrem (Sodium Oxybate) Covered by Aetna CVS Health in New Jersey: Complete Prior Authorization Guide

Answer Box: Your Fastest Path to Xyrem Coverage

To get Xyrem (sodium oxybate) covered by Aetna CVS Health in New Jersey, you need: (1) confirmed narcolepsy diagnosis with sleep study results, (2) documented failure of stimulants/modafinil (unless contraindicated), and (3) REMS enrollment. Submit prior authorization via CVS Caremark at 1-866-785-5714 with sleep specialist documentation. If denied, you have 180 days to appeal internally, then can file external review through New Jersey's IHCAP program with Maximus (888-866-6205).

Table of Contents

What This Guide Covers

This guide helps patients and healthcare providers navigate Aetna CVS Health's prior authorization process for Xyrem (sodium oxybate) in New Jersey. Xyrem is an FDA-approved treatment for cataplexy and excessive daytime sleepiness in narcolepsy patients aged 7 and older. With retail prices around $18,968 for a three-month supply, getting insurance coverage is essential for most families.

Who this helps:

  • Patients with narcolepsy seeking Xyrem coverage
  • Healthcare providers submitting prior authorizations
  • Families navigating insurance denials and appeals

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical documentation to create targeted, evidence-backed rebuttals. Our platform helps patients and providers get specialty medications approved faster by addressing the specific reasons for denial with the right clinical evidence and procedural requirements.

Before You Start: Verify Your Coverage

Check Your Plan Type

Aetna CVS Health offers different plan types with varying coverage rules:

  • Commercial/employer plans: Standard PA requirements apply
  • Medicare Advantage: May have different formulary tiers
  • Medicaid managed care: State-specific criteria may apply

Confirm Formulary Status

Xyrem appears as non-formulary (NF) or Tier 5 in most 2026 Aetna formularies, meaning prior authorization is required. Check your specific formulary at aetna.com/formulary.

Verify Network Status

Ensure your prescribing physician (sleep specialist, neurologist, or pulmonologist) is in-network with your Aetna plan. Out-of-network prescribers may face additional hurdles.

Gather What You Need

Essential Documentation Checklist

Requirement Details Source
Diagnosis Confirmation ICD-10 code G47.411 (narcolepsy with cataplexy) or G47.419 (without cataplexy) Sleep study reports
Sleep Studies Polysomnography (PSG) + Multiple Sleep Latency Test (MSLT) Sleep lab results
Prior Therapy History Records of failed stimulants, modafinil/armodafinil trials (≥2 months each) Medical records
REMS Enrollment Patient and prescriber enrollment confirmation Jazz Pharmaceuticals
Prescriber Credentials Sleep specialist, neurologist, or pulmonologist certification Medical license verification

REMS Enrollment Process

All patients must complete REMS enrollment before receiving Xyrem. This is a one-time requirement managed by Jazz Pharmaceuticals:

  1. Patient enrollment: Complete the XYWAV and XYREM Patient Enrollment Form
  2. Submission options: Online at xywavxyremrems.com, email to [email protected], or fax
  3. Support: Call 1-866-997-3688 for assistance
  4. Timeline: Process typically takes 1-2 business days

Step Therapy Requirements

For patients ≥18 years with excessive daytime sleepiness:

  • Must have inadequate response, intolerance, or contraindication to both modafinil and armodafinil
  • Document at least 2 months of therapy for each (unless contraindicated)

For patients 7-17 years:

  • Must have inadequate response, intolerance, or contraindication to at least one CNS stimulant (amphetamine, methylphenidate)

For cataplexy (any age ≥7 years):

  • Must have ≥3 cataplexy attacks per week at baseline
  • Sleep lab confirmation required

Submit the Prior Authorization Request

CVS Caremark Submission Process

Aetna uses CVS Caremark for specialty drug prior authorizations:

Contact Information:

  • Phone: 1-866-785-5714
  • Fax: Submit PA form with required documentation
  • Form: Request form 1481-A for Xyrem submissions

Required Submission Elements

  1. Completed PA form with patient demographics and insurance information
  2. Sleep specialist's medical necessity letter addressing:
    • Confirmed narcolepsy diagnosis with sleep study results
    • Symptom severity (cataplexy frequency, Epworth Sleepiness Scale score)
    • Prior medication trials and outcomes
    • Clinical rationale for Xyrem therapy
  3. Supporting documentation:
    • Sleep study reports (PSG and MSLT)
    • Prior medication trial records
    • REMS enrollment confirmation
    • Progress notes from sleep specialist
Tip: Submit a complete "request packet" to avoid delays. Missing documentation is the most common reason for processing delays.

Follow-Up and Timelines

Standard Processing Times

  • Initial review: 30-45 days for standard requests
  • Expedited review: ≤72 hours for urgent medical needs
  • Medicare plans: ≤72 hours for expedited requests

When to Follow Up

  • Day 3: Confirm CVS Caremark received your submission
  • Day 10: Check processing status
  • Day 25: Request status update if no decision received

Sample Follow-Up Script

"Hi, I'm calling to check the status of a prior authorization request for Xyrem submitted on [date]. The patient name is [name], member ID is [number], and the reference number is [if available]. Can you tell me the current status and if any additional information is needed?"

If You're Asked for More Information

CVS Caremark may request additional documentation such as:

  • Detailed symptom diary: Document cataplexy episodes or sleep attacks
  • Additional sleep studies: If previous studies are older than 2 years
  • Contraindication documentation: Medical records showing why standard therapies can't be used
  • Weight-based dosing justification: For pediatric patients

Response timeline: You typically have 14 days to submit additional information. Submit via the same fax number used for the original request.

If Your Request Is Denied

Understanding Denial Codes

Common denial reasons for Xyrem include:

  • No REMS enrollment: Complete enrollment before resubmission
  • Insufficient step therapy: Document additional medication trials
  • Incomplete sleep studies: Provide both PSG and MSLT results
  • Off-label use: Xyrem is only covered for FDA-approved narcolepsy indications

Internal Appeal Process

You have 180 days from the denial date to file an internal appeal with Aetna:

  1. Gather additional evidence: Updated medical records, peer-reviewed literature, clinical guidelines
  2. Medical necessity letter: Have your sleep specialist write a detailed rebuttal addressing the specific denial reason
  3. Submit appeal: Use Aetna's member portal or mail to the address on your denial letter

Appeal timeline: Aetna must respond within 30 days for standard appeals, 72 hours for expedited appeals.

New Jersey External Appeals (IHCAP)

If Aetna upholds their denial after internal appeals, New Jersey's Independent Health Care Appeals Program (IHCAP) provides an independent review.

IHCAP Process Overview

Administered by: Maximus Federal Services
Contact: 888-866-6205
Portal: njihcap.maximus.com
Cost: Free to patients

Timeline for External Review

Stage Timeline Details
Preliminary Review 5 business days Maximus confirms eligibility and completeness
Full Review 45 calendar days (standard) Independent physician panel reviews case
Expedited Review 48 hours For urgent medical situations
Implementation 14 days (standard), 72 hours (expedited) Aetna must authorize coverage if approved

Required Documentation for IHCAP

  • Initial denial letter from Aetna
  • Internal appeal decision(s)
  • Medical records supporting medical necessity
  • Sleep specialist's letter explaining why Xyrem is appropriate
Note: IHCAP decisions are binding on insurance companies. If they approve your request, Aetna must provide coverage.

When preparing for an external appeal, Counterforce Health can help analyze your denial letter and create a targeted rebuttal that addresses the specific medical necessity criteria used by independent review organizations.

Renewal and Re-authorization

Annual Renewal Requirements

Xyrem prior authorizations typically require annual renewal. Start the process 30-60 days before your current authorization expires.

Renewal documentation needed:

  • Updated medical records showing continued medical necessity
  • Documentation of treatment response (reduced cataplexy episodes or improved daytime alertness)
  • Confirmation of ongoing REMS compliance
  • Sleep specialist's letter supporting continued therapy

What Speeds Renewal

  • Consistent specialty pharmacy fills
  • Documented symptom improvement
  • No safety concerns or medication adherence issues
  • Updated sleep studies if clinically indicated

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
No REMS enrollment Complete enrollment before resubmission REMS confirmation from Jazz
Insufficient step therapy Document modafinil/armodafinil trials Pharmacy records, provider notes
Missing sleep studies Submit PSG and MSLT results Sleep lab reports with interpretation
Off-label indication Confirm narcolepsy diagnosis ICD-10 G47.411 or G47.419 documentation
Quantity limits exceeded Justify dosing based on weight/response Provider letter with clinical rationale

Costs and Patient Support

Manufacturer Support Programs

Jazz Cares: Provides copay assistance and patient support services

  • Phone: 1-866-757-5292
  • Eligibility: Commercial insurance patients with qualifying income
  • Coverage: May reduce copay to as low as $35/month

Additional Resources

  • Patient Advocate Foundation: Financial assistance for medication costs
  • NeedyMeds: Database of patient assistance programs
  • GoodRx: Discount programs (though limited for specialty drugs)

FAQ

How long does Aetna CVS Health prior authorization take in New Jersey?
Standard requests take 30-45 days. Expedited requests for urgent medical needs are processed within 72 hours.

What if Xyrem is non-formulary on my plan?
You can request a formulary exception with medical necessity documentation. The process is similar to prior authorization but may require additional clinical justification.

Can I request an expedited appeal if denied?
Yes, if a delay in treatment would seriously jeopardize your health. Your sleep specialist must provide documentation supporting the urgent medical need.

Does step therapy apply if I tried medications outside New Jersey?
Yes, medication trials from other states count toward step therapy requirements as long as you have proper documentation from the prescribing physician.

What happens if my sleep specialist isn't REMS-enrolled?
Your doctor must complete REMS enrollment before prescribing Xyrem. This is a federal requirement that cannot be waived.

How do I know if my appeal was successful?
You'll receive written notification from Aetna within 30 days for standard appeals. Check your member portal for real-time status updates.

Sources & Further Reading

Disclaimer: This guide is for informational purposes only and does not constitute medical advice. Always consult with your healthcare provider about treatment decisions. Insurance coverage policies may change; verify current requirements with your plan. For additional help with insurance appeals in New Jersey, contact the Department of Banking and Insurance Consumer Hotline at 1-800-446-7467.

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