Does Medicare Cover Xyrem?

Xyrem helps manage narcolepsy accompanied by cataplexy, a symptom characterized by a loss of muscle tone while you're awake. When you take this drug, its active ingredient — sodium oxybate — reduces daytime sleepiness and causes fewer episodes of sudden muscle weakness. Keep reading to find out what you can expect if you have Medicare coverage and need to fill a Xyrem prescription.

What Is Xyrem Prescribed For?

Xyrem treats narcolepsy, a condition that causes daytime drowsiness and sudden "sleep attacks." No matter how much you have to accomplish, narcolepsy makes it difficult to stay awake. In some people, it also causes cataplexy, which can interfere with your daily routine.

How Does Xyrem Treat Narcolepsy?

Xyrem helps control narcolepsy symptoms by suppressing the central nervous system (CNS). This type of drug helps you get more deep sleep at night, so you don't get as sleepy during the day.

Medicare Coverage of Xyrem

Approximately 97% of Medicare prescription drug plans cover Xyrem. Before you fill your prescription, you may need to get prior authorization from Medicare. If your plan requires prior authorization, ask your health care provider to submit a PA form to Medicare on your behalf. Medicare won't cover Xyrem until this form has been approved.

How Much Does Xyrem Cost With Medicare?

How much you pay for Xyrem depends on what Medicare plan you have. You also need to think about whether you're in the deductible stage, the initial coverage stage or the donut hole stage. During the deductible stage, you haven't met your annual deductible. Some plans have $0 deductibles, while others have deductibles of up to $545 per year, so your deductible costs will vary.

Once you satisfy your deductible, you'll enter the initial coverage stage, which is when you pay a co-pay or coinsurance for every prescription. A co-pay is a flat fee (e.g. $20), while coinsurance is a percentage of the cost of the drug. If you're in the donut hole, Medicare limits how much it pays toward each prescription. That means it may cost more to fill your Xyrem prescription. Although Xyrem costs are plan-dependent, all Medicare prescription drug plans have a maximum deductible of $545 per year in 2024.