Does Medicare Cover Xyrem? 

The balance between sleep and brain function can be delicate. While many people face occasional insomnia or mild sleep issues, some seniors experience chronic, moderate to severe issues that disrupt their daily life. Chronic disorders such as narcolepsy can be detrimental to physical, mental, emotional and social health on an ongoing basis. Narcolepsy can also affect your ability to live and work independently, so it’s important to talk to your doctor to discuss treatment options. 

What is narcolepsy?

Narcolepsy is a neurological disorder that commonly manifests as the inability to stay awake during normal hours. Someone with narcolepsy may fall asleep suddenly at inopportune or inappropriate times. Additionally, narcolepsy can cause muscle weakness and instability, potentially leading to falls and injuries.

It’s believed that narcolepsy is a genetic condition, but certain external factors like psychological stress can make symptoms worse. Hormonal changes with age can also affect the severity of narcolepsy symptoms in seniors. In severe cases, hallucinations and sleep paralysis may accompany narcolepsy.

How is narcolepsy treated in seniors?

Narcolepsy can develop at any stage of life, but it is most commonly diagnosed in younger people. Some seniors have lived their entire lives with mild forms of narcolepsy only to get diagnosed in the later stages of life.

Treatment for narcolepsy depends on the severity as well as any confounding factors like lifestyle concerns and environmental stressors. To obtain a diagnosis, a sleep study (polysomnography) will usually be conducted. The results of this sleep study will direct treatment.

In terms of prescription treatments for narcolepsy, stimulant medications may be prescribed to help seniors with narcolepsy stay awake. Aside from stimulant medications, central nervous system depressants like Xyrem (sodium oxybate) may be prescribed. Xyrem is a medication that affects GABA-b and GHB receptors in the brain. It’s believed that this activates delta waves to regulate sleep.

Does Medicare cover Xyrem?

Medicare coverage for Xyrem is available under most Part D prescription drug plans. Medicare Part D covers medications that can be purchased from traditional pharmacies to be taken at home. Medications must be prescribed by Medicare-participating physicians qualify for coverage.

Additionally, Medicare coverage is only available for prescriptions that are listed in your plan’s Part D formulary. This is a list of covered medications that is provided with each Part D plan. It details coverage limitations and restrictions and provides other important information about which drugs are covered under a particular Part D plan.

The cost of Xyrem under Medicare Part D

The cost of Xyrem can vary under Part D as each private plan is different. Some Medicare recipients may need to pay a copay charge when purchasing Xyrem.

Part D premium costs

Medicare Part D plans require a monthly premium to keep coverage current. In 2024, the standard premium for Medicare Part D prescription drug coverage is expected to be $55.50, but premium costs can go up with your income. If you earn $103,000 as an individual or you have a household income of $206,000 or less in 2024, you simply pay your plan premium. An additional premium charge known as an income-related monthly adjustment amount (IRMAA) gets added to your monthly costs as your income level goes up.

Part D deductible costs

In 2024, no Part D deductible can be higher than $545. This is the amount in prescription drug costs you will need to spend out of pocket before your Medicare benefits apply toward the cost of your covered medications.

A word of caution about Xyrem

Xyrem is potentially dangerous when not taken as directed. Medicare recipients who have been prescribed Xyrem are encouraged to speak with both their doctors and pharmacists about the risks associated with Xyrem. Because this medication is a central nervous system depressant, the potential for adverse outcomes and abuse is higher than that of some other medications.