Prescriber Enrollment

Prescribers must enroll one time in the XYREM® REMS Program and agree to comply with the requirements to ensure safe use1

Prescribers should refer to the XYREM REMS Program Prescriber Brochure for details on enrollment requirements. Available at XYREMREMS.com.

To enroll in the XYREM REMS Program, prescribers will1:

review Review

Review the XYREM full Prescribing Information (PI) and XYREM REMS Program Prescriber Brochure.

Prescribers must understand important prescribing information such as the approved indications, risks, and safe use conditions of XYREM in addition to the XYREM REMS Program requirements.

The XYREM full Prescribing Information (PI) and XYREM REMS Program Prescriber Brochure are available at XYREMREMS.com.

complete Complete

Complete the one-time XYREM REMS Program Prescriber Enrollment Form.

Prescribers need only enroll one time. However, new prescribers are encouraged to submit a Prescriber Enrollment Form for each practice location to ensure timely fulfillment of the patient’s prescription.

By signing the Prescriber Enrollment Form, the prescriber:

  • Acknowledges understanding of important information about XYREM, including approved indications and serious risks.
  • Agrees to comply with the program requirements to ensure safe use.
All required fields must be completed clearly and accurately for timely enrollment. Required fields are indicated by an asterisk (*).

The XYREM REMS Program Prescriber Enrollment Form is available for download or online submission at XYREMREMS.com.

submit Submit

Submit the completed and signed XYREM REMS Program Prescriber Enrollment Form to the Certified Pharmacy.

The Certified Pharmacy will notify prescribers when they are successfully enrolled and eligible to prescribe XYREM.1

Download forms or enroll at XYREMREMS.com

Need Help? Have Questions?

Call the XYREM REMS Program hotline anytime.

The Certified Pharmacy provides 24/7 toll-free access to a pharmacist to help answer any questions or concerns the prescriber, office staff, or patients may have regarding safety, dosing, and patient care.

Frequently Asked Questions

Yes. All Prescribers must enroll in the XYREM REMS Program before prescribing XYREM.1

To enroll in the XYREM REMS Program, prescribers must review the XYREM full Prescribing Information (PI) and XYREM REMS Program Prescriber Brochure, and complete and submit the one-time XYREM REMS Program Prescriber Enrollment Form.1

By signing the Prescriber Enrollment Form, the prescriber acknowledges understanding of important information about XYREM, including the approved indications and serious risks, and agrees to comply with program requirements to ensure safe use. Prescribers must submit the completed and signed Prescriber Enrollment Form to the Certified Pharmacy by either faxing to 1-866-470-1744 (toll free), scanning and emailing to XYREMPrescribers@express-scripts.com, or mailing to XYREM REMS Program, PO Box 66589, St. Louis, MO 63166-6589.1 Secure online enrollment is also available at XYREMREMS.com.

Prescribers should refer to the XYREM REMS Program Prescriber Brochure for details on enrollment requirements.1

For new prescribers, enrollment for each practice location is encouraged to ensure timely fulfillment of a patient’s prescription; this is best done by submitting a Prescriber Enrollment Form for each office location.

If your location, phone, or fax number changes, fill in the new information on the next XYREM REMS Program Prescription Form you submit to the Certified Pharmacy. Verification of all new information will be completed upon receipt. Prescribers do not need to send in a new Prescriber Enrollment Form to communicate change of address or contact information.

Changes in contact information should be added to the next XYREM REMS Program Prescription Form submitted to the Certified Pharmacy. Verification of all new information will be completed upon receipt. Prescribers do not need to send in a new Prescriber Enrollment Form to communicate change of address or contact information.

Editable versions of the XYREM REMS Program Prescriber Enrollment Form and XYREM REMS Program Patient Enrollment Form, as well as secure online prescriber and patient enrollment, are available at XYREMREMS.com. All required forms can also be obtained by contacting a Jazz Pharmaceuticals Specialty Sales Consultant (SSC) or calling the Certified Pharmacy. XYREM REMS Program Prescription Forms are not available online.

The XYREM REMS Program education material can be downloaded from XYREMREMS.com. The XYREM REMS Program education material may also be obtained by contacting a Jazz Pharmaceuticals Specialty Sales Consultant (SSC) or calling the Certified Pharmacy.

Yes. Secure online enrollment for prescribers and patients is available at XYREMREMS.com. The XYREM REMS Program Prescriber Enrollment Form can also be scanned and submitted via email.

The XYREM REMS Program Prescription Form is not available electronically.

In addition to confirming receipt of all completed forms, the Certified Pharmacy will reach out to the designated office contact or prescriber to notify him or her if any form contains insufficient or incorrect information.1

For the XYREM REMS Program Prescriber Enrollment Form and XYREM REMS Program Patient Enrollment Form, the Certified Pharmacy can verbally obtain certain missing information (ie, demographic information) by contacting the prescriber office, and complete the enrollment process. Forms will be returned to the prescriber if checkboxes or signature/date fields are left blank. All forms will be returned to the prescriber if the Certified Pharmacy is unable to reach the prescriber via phone. In these cases, the prescriber will receive a fax notification including a copy of the submitted form, with instructions to complete and resubmit the form to the Certified Pharmacy.