Form 1356, Xyrem Standard PA Addendum (Medicaid)

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Documents

Effective Date: 5/2018

Instructions

Update: 5/2018

Purpose

For prescribing providers to request pharmacy prior authorization for Xyrem® (sodium oxybate).

When to Prepare

Detailed Instructions

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

Transmittal

  • Fax: 866-469-8590

Questions