CurrentCignaPolicy IP0102

Sunosi (solriamfetol) drug coverage

Cigna coverage policy for Sunosi (solriamfetol) for treatment of excessive daytime sleepiness in adults with narcolepsy or obstructive sleep apnea; describes medical necessity criteria, documentation, and exclusions affecting benefit determination.

Policy Summary

PayerCigna

PolicySunosi (solriamfetol) drug coverage

Policy CodePolicy IP0102

Change TypeRevised coverage criteria and prior therapy requirements

Effective DateMar 1, 2025

Next Review Date

Key ActionSubmit prior authorization with documentation of PSG/MSLT for narcolepsy, prior trial of generic modafinil or generic armodafinil (or CNS stimulant exception), and prescriber specialty (sleep specialist or neurologist).

SourceLink

POLICY UPDATE CHANGES

Expanded required prior therapy for narcolepsy to include a CNS stimulant, generic modafinil, or generic armodafinil (with exception for prior brand Provigil or Nuvigil).

Narcolepsy documentation requirement changed to 'Documentation that the patient has been evaluated using polysomnography and a multiple sleep latency test' and 'Documented diagnosis of narcolepsy has been confirmed.'

OSA criteria updated to allow approval when Sunosi is used with CPAP or when patient is unable to initiate or tolerate CPAP; prior requirement for a month of non-pharmacologic treatment was removed.

Explicit 'Conditions Not Covered' entry added prohibiting concomitant use of Sunosi with oxybate products and/or Wakix (pitolisant).

Requirement that medication be prescribed by or in consultation with a sleep specialist physician or neurologist (pulmonologist removed).

2FDA-approved indications (narcolepsy, OSA)

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Coverage Criteria for Sunosi (solriamfetol)

Covered: Excessive Daytime Sleepiness Associated with Narcolepsy (FDA-approved)

Approve for 1 year if ALL of the following are met:

Narcolepsy approval criteria: A) Patient is >= 18 years of age; AND B) Documentation that the patient has been evaluated using polysomnography and a multiple sleep latency test; AND C) Documented diagnosis of narcolepsy has been confirmed; AND D) The medication is prescribed by or in consultation with a sleep specialist physician or a neurologist; AND E) Documentation that the patient has tried at least ONE of the following treatments: a central nervous system (CNS) stimulant, generic modafinil, or generic armodafinil. Note: examples of CNS stimulants include methylphenidate, dexmethylphenidate, and dextroamphetamine. An exception to the prior therapy requirement is allowed if the patient has previously tried brand Provigil or brand Nuvigil.

Initial approval duration = 1 year

Covered: Excessive Daytime Sleepiness Associated with Obstructive Sleep Apnea (FDA-approved)

Approve for 1 year if ALL of the following are met:

OSA approval criteria: A) Patient is >= 18 years of age; AND B) Patient meets one of the following: (i) Sunosi will be used in conjunction with continuous positive airway pressure (CPAP) therapy; OR (ii) Documentation that the patient is unable to initiate or tolerate CPAP therapy; AND C) Documentation that the patient has tried generic modafinil or generic armodafinil. Note: an exception to the prior therapy requirement is allowed if the patient has previously tried brand Provigil or brand Nuvigil.

Initial approval duration = 1 year

Any use of Sunosi (solriamfetol) outside the FDA‑approved indications for narcolepsy or obstructive sleep apnea is considered experimental, investigational, or unproven. The policy explicitly lists non‑covered scenarios and notes that the list may not be all‑inclusive; determinations will be updated as new published data become available.

The concomitant use of Sunosi with oxybate products (Xyrem, Lumryz, Xywav) or with Wakix (pitolisant) is considered unproven and is not covered. The policy states that these oxybate products share the same active ingredient (oxybate), are central nervous system depressants, and that there are no published studies evaluating combination or alternating use with Sunosi.

Key Diagnostic Thresholds

MSLT mean sleep latency — numeric threshold

MSLT mean sleep latency threshold<= 8 minutes (mean sleep latency < 8 minutes over five MSLT naps indicates excessive daytime sleepiness)

Test formatFive nap opportunities separated by ~2 hours on the day after an overnight PSG

Clinical implicationMean sleep latency < 8 minutes supports diagnosis of excessive daytime sleepiness consistent with narcolepsy

SOREMPs on MSLT/PSG — required count details

Required SOREMP count for narcolepsy>= 2 SOREMPs across the MSLT naps and nocturnal PSG (REM onset within 15 minutes at least two times out of the five naps and the night before)

Alternate SOREMP patternREM onset within 15 minutes on multiple MSLT naps and also observed on the preceding nocturnal PSG suggests narcolepsy-related REM dysregulation

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization required. Documentation must demonstrate the patient meets the specified criteria for the FDA‑approved indication requested and support medical necessity for coverage.

Prior authorization required for Sunosi (solriamfetol) requests.
Approve initial requests for up to 1 year when criteria are met.

Step Therapy

Prior Therapy Requirement

Prior therapy requirement: Patient must have tried specified prior therapies before Sunosi is approved, with limited exceptions for prior brand therapy.

For narcolepsy: Patient is ≥ 18 years and has tried at least ONE of the following: a central nervous system (CNS) stimulant (examples: methylphenidate, dexmethylphenidate, dextroamphetamine), generic modafinil, or generic armodafinil. Exception: prior use of brand Provigil or brand Nuvigil satisfies the requirement.
For OSA with excessive daytime sleepiness: Patient is ≥ 18 years and has tried generic modafinil or generic armodafinil. Exception: prior use of brand Provigil or brand Nuvigil satisfies the requirement.

Background on Sunosi

Sunosi (solriamfetol) is a dopamine and norepinephrine reuptake inhibitor indicated to improve wakefulness in adults with excessive daytime sleepiness due to narcolepsy or obstructive sleep apnea. The mechanism is wakefulness‑promoting via inhibition of dopamine and norepinephrine reuptake. Diagnosis of narcolepsy typically requires specialized testing such as an overnight polysomnogram followed by a multiple sleep latency test to document excessive daytime sleepiness and REM sleep onset (SOREMPs).

Diagnostic Test Definitions

Polysomnogram (PSG) / Multiple Sleep Latency Test (MSLT) — definitions and what they measure

Polysomnogram (PSG)An overnight recording of brain and muscle activity, breathing, and eye movements; used to evaluate nocturnal sleep and to precede the MSLT

Multiple Sleep Latency Test (MSLT)Daytime test performed the day after PSG consisting of five short naps separated by ~2 hours to measure how quickly the patient falls asleep (mean sleep latency) and whether REM onset occurs

What they measureMSLT measures mean sleep latency (sleep onset speed) and REM onset (SOREMPs); PSG characterizes nocturnal sleep and documents REM latency relevant to SOREMP assessment

Interpretation criteriaMean sleep latency < 8 minutes indicates excessive daytime sleepiness; REM onset within 15 minutes on multiple naps and on nocturnal PSG (>=2 occurrences) supports narcolepsy

Initial Therapy — Medical Necessity Criteria

Initial therapy

Initial approval criteria

Initial: See coverage criteria sets for narcolepsy and OSA; initial approvals are granted for 1 year with required documentation as specified (including PSG/MSLT for narcolepsy, prescriber specialty, and prior therapy trials).

Prior authorization required; documentation may include chart notes, laboratory tests, claims records, and/or other information.

Continuation Therapy Criteria

Continuation therapy

Continuation requests

Continuation: Coverage continuation beyond initial approval should be based upon clinical response, continued indication, and adherence to therapy; subsequent approvals require documentation of ongoing benefit and continued appropriate use.

Initial approvals are for 1 year; documented clinical benefit expected for renewal.

Step Therapy / Prior Trial Requirements

Prior step	Required trial	Exceptions / notes
Step 1	Documentation of trial of generic modafinil or generic armodafinil prior to approval	For narcolepsy, an alternative prior trial of a CNS stimulant is acceptable (examples: methylphenidate, dexmethylphenidate, dextroamphetamine). An exception to the generic modafinil/armodafinil requirement is allowed if the patient previously tried brand Provigil or brand Nuvigil.

Site of Care and Prescriber Requirements

Note

Office: clinically appropriate dosing, site of care, and prescriber specialty

Ensure dose, frequency, duration, and site of care are reasonable and clinically appropriate and supported by evidence-based literature. Sunosi must be prescribed by or in consultation with a sleep specialist physician or a neurologist for narcolepsy approval.

Dose, frequency, duration, and site of care should be supported by evidence-based literature
Medication must be prescribed by or in consultation with a sleep specialist or neurologist (pulmonologist removed)

Policy Summary

PayerCigna

PolicySunosi (solriamfetol) drug coverage

Policy CodePolicy IP0102

Change TypeRevised coverage criteria and prior therapy requirements

Effective DateMar 1, 2025

Next Review Date

SourceLink

On This Page

Documentation Required

Required Documentation to Support Approval

Documentation required to support approval. Provide clinical records that verify diagnosis, testing, prior therapies, and prescriber specialty where indicated.

Documentation may include chart notes, polysomnography and multiple sleep latency test results, claims records, laboratory tests, and/or other supporting information.
For narcolepsy: documentation of confirmed narcolepsy diagnosis and evidence of evaluation with polysomnography and a multiple sleep latency test.
For OSA: documentation that Sunosi will be used in conjunction with CPAP therapy OR documentation that the patient is unable to initiate or tolerate CPAP therapy.
Include documentation of prior medication trials (generic modafinil or armodafinil, CNS stimulant, or prior brand Provigil/Nuvigil where applicable).
Prescriber requirement: medication prescribed by or in consultation with a sleep specialist or neurologist.

Denial Risk

Not Covered Uses / Disallowed Combination Therapy

Not covered uses and disallowed combination therapy. Requests for non‑FDA indicated uses or for concomitant use with specific products are not covered.

Any use other than excessive daytime sleepiness due to narcolepsy or obstructive sleep apnea is considered experimental, investigational, or unproven and is not covered.
Concomitant use of Sunosi with an oxybate product (Xyrem, Lumryz, Xywav) and/or Wakix (pitolisant) is not covered due to lack of evidence on combination safety and efficacy.