CurrentCignaPolicy N/A

Sunosi (solriamfetol) Drug Quantity Management — Coverage Criteria

Defines quantity limits and exception criteria for Sunosi (solriamfetol) tablets for Cigna-administered health benefit plans, affecting prescribers and pharmacists requesting coverage.

Policy Summary

PayerCigna

PolicySunosi (solriamfetol) Drug Quantity Management — Coverage Criteria

Policy CodePolicy N/A

Change TypeClarification

Effective DateN/A

Next Review DateSep 6, 2024

Key ActionIf quantity rules are not met, request a one-time override (approved for 30 days) per the listed criteria when titrating from 75 mg to 150 mg.

SourceLink

POLICY UPDATE CHANGES

Policy Statement was updated to note that 'one-time' approvals are provided for 30 days in duration.

30max tablets per retail Rx

90max tablets per home delivery Rx

60one-time retail override

120one-time home delivery override

30done-time approval duration

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Coverage Criteria

Titration override (75 mg to 150 mg)

Exceptions to the listed quantity limits are covered as medically necessary when ALL of the following are met:

Titration override for 75 mg to 150 mg: Patient is actively titrating dose from 75 mg once daily to 150 mg once daily.one-time override quantities: retail = 60 tablets; home delivery = 120 tablets

Home delivery quantity (120 tablets) provides supply for 60 days of 75 mg QD and up to 30 days of 150 mg QD. Approvals are one-time and provided for 30 days in duration.

150 mg tablet quantity policy

Standing policy for Sunosi 150 mg tablets:

150 mg tablet policy: No overrides are recommended for Sunosi 150 mg tablets.no override

Any request for quantities exceeding the stated Drug Quantity Limits that does not meet the listed exception criteria is considered not medically necessary.

Any exception beyond those specifically listed in this policy is considered not medically necessary.

Coding & Dosing Details

Covered CPT Codes, Not Covered, Experimental, Cosmetic, Presumptivemixed

No codes listed

Maximum recommended daily dose

Maximum recommended daily dose150 mg once daily

Dose-related safety noteDoses >150 mg QD are not recommended due to increased adverse reactions

Titration interval referenceDose may be increased after at least 3 days based on tolerability

Initial OSA dose

Initial OSA dose37.5 mg once daily

Dose range for OSA37.5–150 mg once daily

Titration guidance

Provider Actions & Requirements

Prior Authorization

Quantity management override

One-time quantity management overrides are approved for 30 days. Use this override when the Drug Quantity Management rule is not met at point of service to allow a short-term supply while completing titration or other transition needs.

One-time approvals: 30 days

Denial Risk

Quantity limit denial risk

Claims exceeding drug quantity limits without meeting the exception criteria will be considered not medically necessary and may be denied. Review the Drug Quantity Limits and associated exception criteria before submitting requests.

Retail maximum per Rx: 30 tablets (75 mg or 150 mg)
Home delivery maximum per Rx: 90 tablets (75 mg or 150 mg)
Exceptions covered only when criteria are met

Background

Sunosi (solriamfetol) is a dopamine and norepinephrine reuptake inhibitor indicated to improve wakefulness in adults with excessive daytime sleepiness associated with narcolepsy or obstructive sleep apnea (OSA). Dosing recommendations vary by indication and renal function, with a maximum recommended dose of 150 mg once daily. Quantity limits for Sunosi tablets are set in this policy to manage dosing consolidation and prevent stockpiling, with retail limits of 30 tablets per Rx and home delivery limits of 90 tablets per Rx for both 75 mg and 150 mg strengths.

Definitions & Special Populations

Indications

Indications (covered)Narcolepsy

Indications (covered)Obstructive sleep apnea (OSA)

Clinical effectImproves wakefulness in adults with excessive daytime sleepiness associated with narcolepsy or OSA

Renal impairment — dosing adjustments

eGFR ≥60 mL/min/1.73 m2Standard dosing up to 150 mg once daily as clinically indicated

Moderate renal impairment (eGFR 30–59 mL/min/1.73 m2)Maximum recommended daily dose 75 mg

Severe renal impairment (eGFR 15–29 mL/min/1.73 m2)

Initial Therapy Criteria

Initial dosing

Recommended initial dosing by indication:

Narcolepsy initial dosing: Initial recommended dose in adults with narcolepsy is 75 mg once daily; may be increased to 150 mg once daily after at least 3 days based on efficacy and tolerability; maximum recommended dose 150 mg once daily.75-150 mg QD

Doses >150 mg QD are not recommended due to dose-related adverse reactions.

OSA initial dosing: Initial recommended dose in adults with obstructive sleep apnea (OSA) is 37.5 mg once daily; dose range 37.5 mg to 150 mg once daily; dosage may be doubled at intervals of at least 3 days; maximum recommended dose 150 mg once daily.37.5-150 mg QD

Doses >150 mg QD are not recommended due to dose-related adverse reactions.

Quantity Limits

Sunosi 75 mg tablets — retail quantity limit

Product strengthSunosi 75 mg tablets

Maximum tablets per retail Rx30 tablets

Limit typeRetail maximum quantity per prescription

Sunosi 75 mg tablets — home delivery quantity limit

Product strengthSunosi 75 mg tablets (home delivery)

Maximum tablets per home delivery Rx90 tablets

Limit typeHome delivery maximum quantity per prescription

Policy Summary

PayerCigna

PolicySunosi (solriamfetol) Drug Quantity Management — Coverage Criteria

Policy CodePolicy N/A

Change TypeClarification

Effective DateN/A

Next Review DateSep 6, 2024

Key ActionIf quantity rules are not met, request a one-time override (approved for 30 days) per the listed criteria when titrating from 75 mg to 150 mg.

SourceLink

On This Page

Dose may be doubled at intervals of at least 3 days based on efficacy and tolerability

Initial narcolepsy dose

Initial narcolepsy dose75 mg once daily

Dose range for narcolepsy75–150 mg once daily

Titration timingMay increase to 150 mg after at least 3 days based on efficacy and tolerability

Documentation Required

Documentation and billing

Submit prior authorization requests and claims with the appropriate covered diagnosis and the most appropriate procedure/drug codes as of the date of service. Include clinical documentation supporting any requested exception to quantity limits (e.g., titration plan, renal dosing rationale). Claims submitted without covered codes or required documentation may be denied as not covered.

Use most appropriate codes as of date of service
Include supporting clinical documentation for exceptions (titration, renal impairment, etc.)

Step Therapy

Step therapy

No step therapy requirements are specified in this policy for Sunosi.

Maximum recommended daily dose 37.5 mg

End-stage renal disease (eGFR <15 mL/min/1.73 m2)Use not recommended

Sunosi 150 mg tablets — retail quantity limit

Product strengthSunosi 150 mg tablets

Maximum tablets per retail Rx30 tablets

Limit typeRetail maximum quantity per prescription

Sunosi 150 mg tablets — home delivery quantity limit

Product strengthSunosi 150 mg tablets (home delivery)

Maximum tablets per home delivery Rx90 tablets

Limit typeHome delivery maximum quantity per prescription