CurrentColorado Rocky Mountain Health PlansPolicy 2025 P 2171-9

Sunosi® (solriamfetol) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plansopen_in_new

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySunosi® (solriamfetol) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plansopen_in_new

Policy CodePolicy 2025 P 2171-9

Change TypeRevised criteria and authorization duration

Effective DateNov 16, 2025

Next Review Date

Key ActionSunosi requires prior authorization and will be approved only when the documented clinical criteria for narcolepsy or OSA (including sleep study confirmation or prescriber justification) and medication trial history/compliance are met; authorizations are issued for 12 months.

SourceLink

POLICY UPDATE CHANGES

Updated initial authorization to 12 months (noted in 9/2024 review).

Annual reviews with reference updates were performed in multiple years with no changes to clinical coverage criteria.

Changed prior medication trial requirement in OSA section from two medications to one (noted in 8/2020).

2Covered Indications

12 moAuthorization Duration

>=1 mo

Required CPAP/BiPAP trial

Coverage Summary

Defines UnitedHealthcare commercial prior authorization and medical necessity criteria for Sunosi (solriamfetol) for adult patients with excessive daytime sleepiness due to narcolepsy or obstructive sleep apnea (OSA). Prior authorization and medical necessity requirements apply, with specific initial and reauthorization criteria for each indication and program rules (including documentation of sleep study or prescriber justification, prior medication history, and compliance with OSA airway obstruction therapy).

Authorizations (initial and reauthorization) are issued for 12 months.

Authorization duration12 months

OSA severity>= 15 events/hr OR >=5 events/hr with signs/symptoms

Required CPAP/BiPAP trial>= 1 month

Initial Therapy Criteria — Narcolepsy

Initial Authorization - Narcolepsy

Sunosi will be approved based on all of the following criteria:

ALL of the following

Diagnosis of narcolepsy as confirmed by sleep study (unless the prescriber provides justification confirming that a sleep study would not be feasible)
Symptoms of excessive daytime sleepiness (including but not limited to daily periods of irrepressible need to sleep or daytime lapses into sleep) are present
History of failure, contraindication, or intolerance to both of the following:
- ONE of the following stimulant classes
  - Amphetamine based stimulant (e.g., amphetamine, dextroamphetamine)
  - Methylphenidate based stimulant
- ONE of the following wake-promoting agents

Continuation Therapy Criteria — Narcolepsy

Reauthorization - Narcolepsy

Sunosi will be approved for continuation of therapy based on the following criterion:

ALL of the following

Reduction in symptoms of excessive daytime sleepiness associated with Sunosi therapy

Initial Therapy Criteria — Obstructive Sleep Apnea (OSA)

Initial Authorization - Obstructive Sleep Apnea (OSA)

Sunosi will be approved based on all of the following criteria:

ALL of the following

Diagnosis of OSA defined by one of the following
- Fifteen or more obstructive respiratory events per hour of sleep confirmed by a sleep study (unless the prescriber provides justification confirming that a sleep study would not be feasible)
- OR both of the following
  - Five or more obstructive respiratory events per hour of sleep confirmed by a sleep study (unless the prescriber provides justification confirming that a sleep study would not be feasible)
  - AND one or more of the following signs/symptoms are present

Continuation Therapy Criteria — Obstructive Sleep Apnea (OSA)

Reauthorization - Obstructive Sleep Apnea (OSA)

Sunosi will be approved for continuation of therapy based on both the following criteria:

ALL of the following

Reduction in symptoms of excessive daytime sleepiness associated with Sunosi therapy
Patient continues to be fully compliant with ongoing treatment(s) for the underlying airway obstruction (e.g. CPAP, BiPAP)

Provider Actions & Requirements

Prior Authorization

Prior authorization required

Sunosi requires prior authorization and will be approved only when the documented clinical criteria for narcolepsy or OSA (including sleep study confirmation or prescriber justification) and medication trial history/compliance are met; authorizations are issued for 12 months.

Documentation Required

Sleep study documentation or prescriber justification

Provider must document a confirming sleep study for narcolepsy or OSA unless prescriber provides justification that a sleep study is not feasible.

Applicable Codes

Diagnosis codes referenced for automated approval/logicICD-10

No codes listed

Clinical Evidence & References

References include the Sunosi package insert: Sunosi [package insert]. New York, NY: Axsome Therapeutics, Inc; June 2023.

Note: This policy references the Sunosi package insert (Axsome Therapeutics, June 2023) among other clinical sources and periodic program reviews.

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).

Sunosi does not treat the underlying airway obstruction in OSA; standard treatments for airway obstruction (e.g., CPAP, BiPAP) should be used for at least one month prior to initiating Sunosi and must be continued during treatment.

For OSA, diagnosis criteria include either ≥15 obstructive respiratory events per hour or ≥5 events per hour plus one or more signs/symptoms; documentation of sleep study is required unless the prescriber justifies that a sleep study is not feasible.

TermFully compliant

DefinitionOngoing adherence to prescribed treatment(s) for underlying airway obstruction such as CPAP or BiPAP (as documented by provider).

Revision History

9/2024authorization_duration_updatedLatest

Updated initial authorization to 12 months (noted in 9/2024 review).

8/2020prior_medication_trial_revised

Changed prior medication trial requirement in OSA section from trial of two medications to trial of one (noted in 8/2020).

8/2021annual_review

Annual review with reference updates; no changes to clinical coverage criteria.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySunosi® (solriamfetol) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plansopen_in_new

Policy CodePolicy 2025 P 2171-9

Change TypeRevised criteria and authorization duration

Effective DateNov 16, 2025

Next Review Date

SourceLink

On This Page

modafanil (Provigil)

armodafanil (Nuvigil)

Nonrestorative sleep

Waking up with breath holding, gasping, or choking

Habitual snoring noted by bed partner or other observer

Both of the following (treatment of underlying airway obstruction)

Standard treatments for the underlying airway obstruction (e.g., CPAP, BiPAP) have been used for one month or longer
Patient is fully compliant with ongoing treatment(s) for the underlying airway obstruction

History of failure, contraindication, or intolerance to one of the following

armodafinil
modafinil

Documentation Required

Treatment of underlying airway obstruction for OSA

Provider must document use of standard treatments for airway obstruction (e.g., CPAP/BiPAP) for one month or longer and ongoing full compliance to qualify for initiation or reauthorization in OSA.

Documentation Required

Prior medication failure/contraindication/intolerance

Provider must document history of failure, contraindication, or intolerance to required prior stimulants and wake-promoting agents as specified per indication (narcolepsy: stimulant class and modafinil/armodafinil; OSA: modafinil or armodafinil).

Billing Rule

Authorization duration

Authorizations (initial and reauthorization) will be issued for 12 months.

8/2022annual_review

Annual review with reference updates; no changes to clinical coverage criteria.

9/2022annual_review

Annual review/updated references; no changes to clinical coverage criteria.

11/2023annual_review

Annual review with updated references; no changes to clinical coverage criteria.

9/2024annual_review

Annual review with reference updates; initial authorization concurrently updated to 12 months.

9/2025annual_review

Annual review with updated references; no changes to clinical coverage criteria.