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    v1.0.30
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsFlorida AHCA SUNOSI Coverage Criteria | OpenPayer
    Ask Trek AI about this page
    ModifiedAgency for Health Care AdministrationPolicy N/A

    SUNOSI (solriamfetol) Coverage Criteria

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    Prior authorization for SUNOSI (solriamfetol) in adults with narcolepsy or obstructive sleep apnea and associated excessive daytime sleepiness, including initial authorization, continuation, documentation, dosing, and authorization duration requirements.

    Policy Summary
    PayerAgency for Health Care Administration
    PolicySUNOSI (solriamfetol) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateJul 1, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization with documentation of a modafinil or armodafinil trial and failure; for obstructive sleep apnea, also document compliant CPAP use for at least one month before SUNOSI.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    1 yearAuthorization duration
    18+Minimum patient age
    2Covered indications
    75 mg, 150 mgTablet strengths
    Modafinil or armodafinilRequired prior therapy

    Covered Indications

    Narcolepsy initial therapy

    Covered for narcolepsy when all of the following are met.

    • Age: The patient is 18 years of age or older.>= 18 years

    • Narcolepsy diagnosis or documented sleepiness

      • The patient has a diagnosis of narcolepsy according to International Classification of Sleep Disorders (ICSD-3) or Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria.
      • The patient has excessive daytime sleepiness associated with narcolepsy as confirmed by documented sleep testing.

        Examples include polysomnography and multiple sleep latency testing.

    • Prior therapy failure: The patient has tried and failed modafinil or armodafinil.

      Clinical documentation is required.

    Obstructive sleep apnea initial therapy

    Covered for obstructive sleep apnea when all of the following are met.

    • Age: The patient is 18 years of age or older.>= 18 years

    • OSA diagnosis or documented sleepiness

      • The patient has a diagnosis of obstructive sleep apnea according to ICSD-3 criteria.
      • The patient has excessive daytime sleepiness associated with obstructive sleep apnea as confirmed by documented sleep testing.

        Examples include polysomnography and multiple sleep latency testing.

    • CPAP use: The patient has used continuous positive airway pressure (CPAP) compliantly for at least one month before the SUNOSI trial.At least 1 month before SUNOSI trial
    • Prior therapy failure: The patient has tried and failed modafinil or armodafinil.

      Clinical documentation is required.

    • Underlying airway obstruction treatment: Modalities to treat the underlying airway obstruction continue during treatment with SUNOSI.

    Continuation therapy

    Continuation is covered when all of the following are met.

    • Initial criteria: The patient met the applicable initial criteria.
    • Clinical response: Documentation shows improved clinical response.
    • Adverse effects: The patient has not experienced any treatment-restricting adverse effects.
    • Dosing is appropriate as per labeling or is supported by compendia.

    Authorization and Documentation Requirements

    Prior Authorization

    Prior Authorization and Indication Requirements

    Prior authorization is required for Sunosi (solriamfetol) for patients 18 years of age or older who meet the applicable narcolepsy or obstructive sleep apnea (OSA) indication requirements.

    • Applicable indication: narcolepsy or OSA.
    • The diagnosis must meet the policy's applicable diagnostic criteria, or excessive daytime sleepiness must be confirmed by documented sleep testing.
    Step Therapy

    Required Prior Therapies

    Before Sunosi therapy, document a trial and failure of modafinil or armodafinil. For OSA, also document compliant CPAP use for at least one month before the Sunosi trial and continuation of modalities treating the underlying airway obstruction.

    • Modafinil or armodafinil trial and failure requires clinical documentation.
    • OSA requires compliant CPAP use for at least one month before the Sunosi trial.
    • Continue modalities used to treat the underlying airway obstruction during Sunosi treatment.
    Documentation Required

    Narcolepsy Prior-Treatment Documentation

    For narcolepsy, submit clinical documentation showing a trial and failure of modafinil or armodafinil before Sunosi is initiated.

    • Document the prior medication, trial, and treatment failure.
    • The documentation supports the narcolepsy prior-treatment requirement.
    Documentation Required

    OSA Clinical Documentation

    For OSA, document the qualifying diagnosis or excessive daytime sleepiness confirmed by sleep testing, along with required prior therapy and airway-obstruction treatment documentation.

    • OSA diagnosis must meet ICSD-3 criteria, or excessive daytime sleepiness must be confirmed by documented polysomnography, multiple sleep latency testing, or comparable sleep testing.
    • Document compliant CPAP use for at least one month before the Sunosi trial.
    • Document trial and failure of modafinil or armodafinil.
    • Document that treatment modalities for the underlying airway obstruction will continue during Sunosi therapy.
    Documentation Required

    Continuation Documentation

    For continuation authorization, document that the patient met the initial coverage criteria, has demonstrated improved clinical response, and has not experienced treatment-restricting adverse effects. Dosing must be consistent with labeling or supported by compendia.

    • Initial eligibility criteria remain satisfied.
    • Clinical improvement is documented.
    • No treatment-restricting adverse effects have occurred.
    • Dosing is appropriate according to labeling or supported by compendia.
    Denial Risk

    Narcolepsy Criteria Not Met

    Narcolepsy coverage is not authorized when the patient is under 18, lacks the required narcolepsy diagnosis or documented excessive daytime sleepiness, or has not failed modafinil or armodafinil with supporting clinical documentation.

    • Patient is younger than 18 years of age.
    • Narcolepsy is not established under ICSD-3 or DSM-5 criteria and qualifying excessive daytime sleepiness is not documented by sleep testing.
    • A documented trial and failure of modafinil or armodafinil is absent.
    Denial Risk

    OSA Criteria Not Met

    OSA coverage is not authorized when the patient is under 18, lacks the required OSA diagnosis or documented excessive daytime sleepiness, or has not completed the required OSA prerequisites.

    • Patient is younger than 18 years of age.
    • OSA is not established under ICSD-3 criteria and qualifying excessive daytime sleepiness is not documented by sleep testing.
    • Compliant CPAP use for at least one month before the Sunosi trial is not documented.
    • A documented trial and failure of modafinil or armodafinil is absent.
    • Continuation of modalities treating the underlying airway obstruction is not documented.
    Denial Risk

    Continuation Criteria Not Met

    Continuation is not authorized when initial eligibility is no longer supported, improved clinical response is not documented, treatment-restricting adverse effects are present, or dosing is not consistent with labeling or supported by compendia.

    • Initial coverage criteria were not met or cannot be verified.
    • No clinical improvement is documented.
    • Treatment-restricting adverse effects have occurred.
    • Dosing is inappropriate under labeling and lacks compendia support.

    Policy Background

    SUNOSI (solriamfetol) is covered under this policy for adults with excessive daytime sleepiness associated with narcolepsy or obstructive sleep apnea. For obstructive sleep apnea, modalities addressing the underlying airway obstruction should continue during SUNOSI treatment.

    Initial Authorization Criteria

    Narcolepsy initial therapy

    Initial coverage for narcolepsy requires all applicable criteria.

    Narcolepsy

    • The patient is 18 years of age or older.>= 18 years

    • Narcolepsy diagnosis or documented sleepiness

      • The patient has a diagnosis of narcolepsy according to International Classification of Sleep Disorders (ICSD-3) or Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria.
      • The patient has excessive daytime sleepiness associated with narcolepsy as confirmed by documented sleep testing.

        Examples include polysomnography and multiple sleep latency testing.

    • The patient has tried and failed modafinil or armodafinil.

      Clinical documentation is required.

    Obstructive sleep apnea initial therapy

    Initial coverage for obstructive sleep apnea requires all applicable criteria.

    Obstructive sleep apnea

    • The patient is 18 years of age or older.>= 18 years

    • OSA diagnosis or documented sleepiness

      • The patient has a diagnosis of obstructive sleep apnea according to ICSD-3 criteria.
      • The patient has excessive daytime sleepiness associated with obstructive sleep apnea as confirmed by documented sleep testing.

        Examples include polysomnography and multiple sleep latency testing.

    • The patient has used continuous positive airway pressure (CPAP) compliantly for at least one month before the SUNOSI trial.At least 1 month before SUNOSI trial
    • The patient has tried and failed modafinil or armodafinil.

      Clinical documentation is required.

    • Modalities to treat the underlying airway obstruction continue during treatment with SUNOSI.

    Continuation Authorization

    SUNOSI continuation criteria

    Continuation is covered when all of the following are met.

    SUNOSI continuation therapy

    • Initial criteria: The patient met the applicable initial criteria.
    • Clinical response: Documentation shows improved clinical response.
    • Adverse effects: The patient has not experienced any treatment-restricting adverse effects.
    • Dosing is appropriate as per labeling or is supported by compendia.

    Required Treatment Sequence

    StepRequired prior therapyDocumentation / timing
    1Trial and failure of modafinil or armodafinil before SUNOSIClinical documentation required
    StepRequired prior therapyDocumentation / timing
    2Compliant use of continuous positive airway pressure (CPAP) for obstructive sleep apneaAt least one month before the SUNOSI trial

    Authorization Duration

    Quantity limits
    DrugSUNOSI
    Generic namesolriamfetol
    Authorization durationOne year
    Policy Summary
    PayerAgency for Health Care Administration
    PolicySUNOSI (solriamfetol) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateJul 1, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization with documentation of a modafinil or armodafinil trial and failure; for obstructive sleep apnea, also document compliant CPAP use for at least one month before SUNOSI.
    SourceLink
    On This Page
    Covered IndicationsAuthorization and Documentation RequirementsPolicy BackgroundInitial Authorization CriteriaContinuation AuthorizationRequired Treatment SequenceAuthorization Duration

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