ModifiedHealth NetPolicy CP PMN.209

Solriamfetol (Sunosi) Coverage

Defines medical necessity and prior authorization criteria for solriamfetol (Sunosi) for adults with excessive daytime sleepiness related to narcolepsy or obstructive sleep apnea, and describes approval durations and documentation requirements for Health Net lines of business.

Policy Summary

PayerHealth Net

PolicySolriamfetol (Sunosi) Coverage

Policy CodePolicy CP PMN.209

Change TypeMaterial coverage criteria additions and IL step therapy bypass

Effective DateMay 7, 2019

Next Review DateN/A

Key ActionSubmit prior authorization with MSLT and PSG documentation demonstrating MSLT mean sleep latency < 8 minutes and required SOREMP findings plus ≥3 months of daily irrepressible sleepiness.

SourceLink

POLICY UPDATE CHANGES

Added criteria requiring documentation of MSLT with mean sleep latency < 8 minutes with ≥2 SOREMPs or at least one SOREMP on MSLT plus a SOREMP (<15 minutes) on preceding overnight PSG, and daily periods of irrepressible need to sleep or daytime lapses for ≥3 months for narcolepsy with EDS.

Added step therapy bypass for Illinois HIM per IL HB 5395: step therapy requirements do not apply for Illinois HIM requests as of 1/1/2026.

Updated description section to align with FDA labeling.

2FDA indications

150 mg/dayMax daily dose

12 moApproval duration

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< 8 minDiagnostic threshold

Coverage Criteria for Solriamfetol (Sunosi)

inv-02: Initial Approval — Obstructive Sleep Apnea (OSA)

Covered when ALL of the following are met:

OSA initial criteria: 1) Diagnosis of obstructive sleep apnea (OSA); 2) Age > 18 years; 3) Documented residual excessive sleepiness despite compliant CPAP use as monotherapy for at least 1 month; 4) Failure of a 1-month trial of armodafinil or modafinil at up to maximally indicated doses unless clinically significant adverse effects or contraindications; 5) Dose does not exceed both: (a) 150 mg per day and (b) 1 tablet per day.see node text

Underlying airway obstruction must be treated (e.g., CPAP) before initiating; IL HIM step therapy bypass applies as noted in policy.

inv-03: Continued Therapy

Covered when ONE of the following is met:

Continued therapy criteria: a) Member is currently receiving the medication via the benefit or previously met initial approval criteria AND is responding positively to therapy; OR b) Member is currently receiving medication and is enrolled in a state/product with continuity of care regulations.see node text

If request is for a dose increase, the new dose must not exceed 150 mg/day and 1 tablet/day.

inv-04: Narcolepsy with EDS coverage criteria

Covered when ALL of the following are documented:

Diagnostic testing: MSLT mean sleep latency < 8 minutes AND (two or more SOREMPs on MSLT OR at least one SOREMP on MSLT plus a SOREMP (< 15 minutes) on the preceding overnight PSG).MSLT < 8 minutes; SOREMP < 15 minutes on PSG

Required MSLT/PSG documentation per policy additions.

Clinical history: Daily periods of irrepressible need to sleep or daytime lapses into sleep occurring for at least 3 months.>= 3 months

Required clinical history per policy additions.

Non–FDA‑approved indications for solriamfetol (Sunosi) that are not specifically addressed in this policy are not authorized unless the request includes sufficient documentation of efficacy and safety in accordance with the referenced off‑label use policies (CP.CPA.09 for commercial, HIMPA.154 for Health Insurance Marketplace, and CP.PMN.53 for Medicaid) or the applicable evidence of coverage documents.

When state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid provisions take precedence. Providers should consult the applicable state Medicaid manual for specific coverage rules that supersede this policy for Medicaid members.

Requests for solriamfetol for indications not covered by this policy that lack sufficient off‑label evidence per the referenced off‑label use policies will be considered not medically necessary and may be denied. Providers should supply the required evidence of efficacy and safety consistent with CP.CPA.09, HIMPA.154, or CP.PMN.53 when requesting coverage for off‑label uses.

Key Dosing, Diagnostic Thresholds, and Definitions

Maximum daily dose

Maximum daily dose150 mg/day

MSLT mean sleep latency threshold

MSLT mean sleep latency threshold< 8 minutes

SOREMP timing on PSG

SOREMP timing on PSG< 15 minutes

Symptom duration requirement

Prior Authorization, Documentation, and Step Therapy Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for requests. Provider must submit documentation (such as office chart notes, lab results, or other clinical information) supporting that the member has met all approval criteria, including diagnostic testing and symptom duration.

Approval durations: Medicaid/HIM — 12 months; Commercial — 12 months or duration of request, whichever is less.

Documentation Required

Required Diagnostic Documentation

Documentation must include objective diagnostic testing for narcolepsy with excessive daytime sleepiness (EDS): MSLT results showing mean sleep latency < 8 minutes with evidence of two or more SOREMPs, or at least one SOREMP on MSLT plus a SOREMP (<15 minutes) on the preceding overnight PSG. Also document daily periods of irrepressible need to sleep or daytime lapses into sleep occurring for at least 3 months.

Background and Drug Description

Solriamfetol (Sunosi) is a dopamine and norepinephrine reuptake inhibitor indicated to improve wakefulness in adults with excessive daytime sleepiness (EDS) associated with narcolepsy or obstructive sleep apnea (OSA). For OSA, the policy emphasizes that underlying airway obstruction must be treated (for example, with continuous positive airway pressure) for at least one month prior to initiation and should be continued during treatment, because Sunosi does not treat airway obstruction.

Policy Revision History

2026-01-01policy_changeLatest

Step therapy bypass for Illinois Health Information Model (HIM) added in accordance with Illinois House Bill 5395; step therapy requirements do not apply for Illinois HIM requests as of 1/1/2026.

2019-05-07policy_change

Clinical criteria added requiring documentation of MSLT with mean sleep latency < 8 minutes plus SOREMP findings (≥2 SOREMPs on MSLT or ≥1 SOREMP on MSLT plus a SOREMP <15 minutes on preceding PSG) and history of daily irrepressible sleepiness or daytime lapses for ≥3 months to meet narcolepsy with EDS coverage criteria.

Policy Summary

PayerHealth Net

PolicySolriamfetol (Sunosi) Coverage

Policy CodePolicy CP PMN.209

Change TypeMaterial coverage criteria additions and IL step therapy bypass

Effective DateMay 7, 2019

Next Review DateN/A

Key ActionSubmit prior authorization with MSLT and PSG documentation demonstrating MSLT mean sleep latency < 8 minutes and required SOREMP findings plus ≥3 months of daily irrepressible sleepiness.

SourceLink

On This Page

At least 3 months of daily periods of irrepressible need to sleep or daytime lapses

MSLT (definition)

MSLT definitionMultiple Sleep Latency Test — diagnostic test referenced for confirming narcolepsy with EDS and documenting mean sleep latency and SOREMPs

SOREMP (definition)

SOREMP definitionSleep-onset REM period — REM sleep occurring within 15 minutes of sleep onset and used in narcolepsy diagnostic criteria

SOREMP timing definition

SOREMP timing definitionREM sleep onset within 15 minutes of sleep onset (i.e., SOREMP < 15 minutes)

MSLT mean latency threshold (restated)

MSLT mean latency threshold (restated)Mean sleep latency on MSLT < 8 minutes

Step Therapy

Step Therapy Requirements

Step therapy (prior trials) is required unless exempted. For narcolepsy with EDS and OSA-related residual sleepiness, the provider must document failure of a 1-month trial of armodafinil or modafinil at up to maximally indicated doses, unless clinically significant adverse effects occur or the agents are contraindicated. Additionally, step therapy requires failure of a 1-month trial of a generic central nervous system stimulant (amphetamine, dextroamphetamine, or methylphenidate) at up to maximally indicated doses unless adverse effects or contraindications exist. For Illinois HIM requests, these step therapy requirements do not apply as of 1/1/2026 per IL HB 5395.

Prior authorization may be required for CNS stimulants, armodafinil, and modafinil.
Operational step detail: each required trial = 1 month at maximally indicated dose unless intolerant or contraindicated.

Denial Risk

Requests Lacking Required Documentation

Requests that lack required documentation (MSLT/SOREMP results, PSG documentation when applicable, or documentation of daily irrepressible sleepiness for ≥3 months) or that are for non‑FDA indications without sufficient evidence will be subject to denial or referral to the applicable off‑label policies (CP.CPA.09, HIMPA.154, CP.PMN.53) or evidence of coverage documents.

Missing MSLT/SOREMP or PSG data increases risk of denial.
Non‑FDA indications require sufficient documentation of efficacy/safety per off‑label policies.

Documentation Required

Provider Submission Requirements

Provider must ensure submitted clinical records demonstrate provider qualifications (prescribed by or in consultation with a neurologist or sleep medicine/medicine specialist when required), age criteria, diagnostic test results, prior medication trial details (agent, dose, duration, reason for discontinuation), and symptom history.

Include prescriber specialty and consultation notes when applicable.
Document prior trial duration (1 month) and reason for failure (inefficacy, adverse effect, or contraindication).