CurrentHighmark Blueshield NenyPolicy N/A

Sunosi (solriamfetol) prior authorization form

Provider prior authorization form to request coverage or reauthorization for Sunosi (75mg or 150mg tablets) including member, provider, medication, diagnosis-specific clinical questions (narcolepsy, obstructive sleep apnea), medication history and documentation requirements; includes submission instructions and contact/fax information.

Policy Summary

PayerHighmark Blueshield Neny

PolicySunosi (solriamfetol) prior authorization form

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a completed prior authorization form with member, provider, medication, diagnosis-specific clinical data, medication history and supporting documentation.

POLICY UPDATE CHANGES

No material clinical/coverage changes — this is a payer-specific prior authorization form used to collect clinical information for Sunosi (solriamfetol) requests.

2Available strengths listed

2Diagnosis sections (OSA, Narcolepsy)

3Prior therapy items required

Policy overview

This is a payer-specific prior authorization form used by Highmark BlueShield to request coverage or reauthorization for Sunosi (solriamfetol) in Sunosi 75mg or Sunosi 150mg tablet strengths. The form collects member and provider identification, the requested drug, strength, quantity and requested supply day selection (30 days or 90 days), diagnosis/ICD-10 code(s), and medication history to evaluate medical necessity.

It solicits diagnosis-specific clinical data for narcolepsy and obstructive sleep apnea (OSA), including diagnostic test results (for example, polysomnography AHI, MSLT, MWT, ESS, and CSF hypocretin-1 when applicable), prior treatment failures or intolerances to modafinil, armodafinil, and generic CNS stimulants, and reauthorization improvement data (changes in daytime sleepiness or ESS/MWT).

Submission instructions overview: complete all required information and sign the form, attach supporting clinical documentation, and submit a separate completed prior authorization form for each medication by fax to 1-866-240-8123 or mail to Clinical Services, 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222. The prescribing physician must certify the accuracy and medical necessity of the information; authorization does not guarantee payment and is subject to member eligibility.

What providers must do

Prior Authorization

Submit prior authorization form

A completed prior authorization (PA) form is required for each medication request and reauthorization. The form must include member and provider identifiers, the requested medication and strength/quantity/supply day, diagnosis/ICD-10 code(s), diagnosis-specific clinical data (OSA or narcolepsy sections as applicable), medication history, and any supporting documentation to evaluate medical necessity.

Member and provider information (subscriber ID, name, DOB, provider name, NPI, contact information)
Requested medication, strength, quantity, and supply day (Sunosi 75mg or Sunosi 150mg; 30 or 90 days)
Diagnosis and ICD-10 code(s); applicable diagnosis-specific clinical data (OSA or narcolepsy fields)
Medication history: trials/failure/contraindication/intolerance to modafinil, armodafinil, and/or a generic CNS stimulant
Supporting documentation (diagnostic test results, reauthorization improvement data when applicable)

Documentation Required

Provide diagnostic and prior therapy documentation

Attach diagnostic test results and documentation of prior therapies. Provide the diagnostic test outputs requested for narcolepsy and OSA, and include documentation of trials, failures, contraindications, or intolerance to prior wake-promoting agents and stimulants.

Polysomnography results (AHI, number of SOREMPs as requested)
Multiple Sleep Latency Test (MSLT) results (mean sleep latency, number of SOREMPs)
Maintenance of Wakefulness Test (MWT) results
Epworth Sleepiness Scale (ESS) score
CSF hypocretin-1 level and laboratory reference range (if applicable)
Documentation of trials/failures/intolerance/contraindication to modafinil, armodafinil, and/or generic CNS stimulants

Billing Rule

Submission channels

Fax or mail the completed form and all clinical documentation to the payer using the channels below.

Fax: 1-866-240-8123
Mail: Clinical Services, 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222

Documentation Required

Prescriber signature required

The prescribing physician must sign and date the form certifying that the information provided is true, accurate, complete, and that the requested services are medically indicated and necessary.

Definitions

SOREMP (term)Sleep-onset rapid eye movement period — requested as a count in MSLT and polysomnography sections

AHI (term)Apnea/hypopnea index — reported in events per hour from diagnostic polysomnography

The form's role is to support clinical review for members with narcolepsy or obstructive sleep apnea (OSA) by collecting diagnostic and treatment-failure data relevant to daytime sleepiness and appropriateness of Sunosi therapy. For OSA, the form requests PAP and oral appliance treatment status and tolerance, whether the member remains sleepy despite adequate OSA treatment, exclusion of alternative causes of sleepiness, the polysomnography Apnea/hypopnea index (AHI) in events/hour, and a checklist of relevant symptoms (for example, daytime sleepiness, loud snoring, gasping/choking, cardiovascular and metabolic comorbidities).

For narcolepsy, the form requests baseline measures of excessive daytime sleepiness via the Epworth Sleepiness Scale (ESS) and Maintenance of Wakefulness Test (MWT), detailed MSLT results including mean sleep latency and number of SOREMPs, diagnostic polysomnography SOREMP count, CSF hypocretin-1 level and laboratory reference range when hypocretin deficiency is suspected, and whether the member has a diagnosis of cataplexy.

The form also captures prior medication history to document therapeutic failure, contraindication, or intolerance to generic Modafinil, generic Armodafinil, and a generic CNS stimulant (for example, dextroamphetamine or methylphenidate), plus a free-text field for any other medications tried and failed; these data support the prior authorization determination.