Form 1356, Xyrem Standard PA Addendum (Medicaid)

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Effective Date: 10/2022


Update: 10/2022


Prescribing providers use this form to request pharmacy prior authorization for Xyrem® (sodium oxybate).

When to Prepare

  • Only use this form for people enrolled in Medicaid fee-for-service.
  • Providers should complete all requested information or document why the information is not available. The prescribing provider should sign and submit all requests.
  • This addendum must accompany the Texas Department of Insurance Standard Prior Authorization Form (TDI Form NOFR002 PDF).

Detailed Instructions

  • Staff sends the form to the Medicaid-enrolled pharmacy, who then forwards the completed form by fax.


  • Fax: 866-469-8590