CurrentHealth NetPolicy N/A

Suvorexant (Belsomra) coverage

Defines medical necessity and prior authorization criteria for coverage of suvorexant (Belsomra) for treatment of insomnia for applicable Health Net commercial lines of business.

Policy Summary

PayerHealth Net

PolicySuvorexant (Belsomra) coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization showing diagnosis of insomnia, age eligibility, required prior therapy failures (unless bypass applies), and dosing within limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20 mgmaximum daily dose allowed

10 mgtypical starting dose

12 moapproval duration

≥18minimum age

narcolepsycontraindication

Coverage Criteria

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inv-01: Initial Therapy — Initial Approval (Covered when ALL of the following are met):

Initial Approval (Covered when ALL of the following are met):

Initial Approval Criteria: 1. Diagnosis of insomnia; 2. Age >= 18 years; 3. Failure of zolpidem, zolpidem CR, or temazepam unless member is age >= 65 years, clinically significant adverse effects are experienced, or all are contraindicated; 4. Dose does not exceed 20 mg (1 tablet) per day.

Approval duration: 12 months or duration of request, whichever is less

inv-02: Continuation Therapy — Continuation Therapy (Covered when ALL of the following are met):

Continuation Therapy (Covered when ALL of the following are met):

Continued Therapy Criteria: 1. Member currently receiving medication via Centene benefit or has previously met initial approval criteria (or continuity of care applies); 2. Member is responding positively to therapy; 3. If request is for a dose increase, new dose does not exceed 20 mg (1 tablet) per day.

Approval duration: 12 months or duration of request, whichever is less

Non‑FDA approved indications that are not specifically addressed in this policy are excluded from coverage unless the provider supplies sufficient documentation of efficacy and safety in accordance with the Health Net off‑label use policy (CP CPA.09).

Suvorexant is contraindicated in patients with narcolepsy; requests for members with this condition are excluded from coverage.

Use of suvorexant for indications that are not FDA‑approved and are not addressed by this policy is considered not authorized unless the prescriber provides adequate off‑label documentation per policy CP CPA.09.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Belsomra. Requests must demonstrate the diagnosis of insomnia, member meets age eligibility, prior therapy failures (see required prior trial), dosage limits, and other approval criteria. Approval duration: 12 months or duration of request, whichever is less.

Dose must not exceed 20 mg (1 tablet) per day.
Approval duration: 12 months or duration of request, whichever is less.

Step Therapy

Required Prior Trial

Requests must include documentation showing failure of zolpidem, zolpidem CR, or temazepam prior to approval unless one of the exceptions applies: patient is ≥ 65 years, clinically significant adverse effects experienced, or all listed agents are contraindicated.

Required trial: failure of zolpidem, zolpidem CR, or temazepam.
Exceptions: age ≥ 65 years; clinically significant adverse effects; or contraindications to all alternatives.

Documentation Required

Clinical Documentation Required

Provider must submit supporting clinical documentation with the prior authorization request (for example: office chart notes, recent lab results, or other relevant clinical information) that demonstrates the member meets all approval criteria (diagnosis of insomnia, age ≥ 18 years, response to therapy for continuation requests, and dosing limits).

Examples of documentation: office notes, lab results, medication history, documentation of prior therapy failures, and notes supporting exceptions to prior trial requirement.

Denial Risk

Non‑FDA Indications

Requests for non‑FDA approved (off‑label) indications not addressed in this policy will be denied unless sufficient documentation of efficacy and safety is provided in accordance with the payer's off‑label use policies.

Non‑FDA indications require submission of supporting clinical evidence per off‑label policies (e.g., CP CPA.09 for commercial).

Initial Therapy Criteria

inv-14: Initial therapy — structured initial therapy requirements.

Initial therapy requirements

Initial therapy: Diagnosis of insomnia; age >=18 years; prior trial failure of zolpidem, zolpidem CR, or temazepam unless age >=65 years or clinically significant adverse effects/contraindications to those agents; dose must not exceed 20 mg/day.

Approval duration: 12 months or duration of request, whichever is less

Continuation Therapy Criteria

inv-15: Continued therapy — structured continuation therapy requirements.

Continuation therapy requirements

Continued Therapy: Member currently receiving medication via Centene benefit or has previously met initial approval criteria OR continuity of care applies; member is responding positively to therapy; dose increase requests must not exceed 20 mg/day.

Approval duration: 12 months or duration of request, whichever is less

Step	Required prior trial(s)	Exceptions / Bypass criteria
1	Failure of zolpidem (IR), zolpidem CR, or temazepam prior to initiation	Member age ≥ 65 years; clinically significant adverse effects to the listed agents; or all listed agents are contraindicated

Policy Summary

PayerHealth Net

PolicySuvorexant (Belsomra) coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization showing diagnosis of insomnia, age eligibility, required prior therapy failures (unless bypass applies), and dosing within limits.

SourceLink

On This Page

OpenPayer

Suvorexant (Belsomra) coverage

Coverage Criteria

Coding and Dose Limits

Provider Actions and Requirements

Background

Definitions

Initial Therapy Criteria

Continuation Therapy Criteria

Step Therapy Requirements

Quantity Limits