CurrentHighmark Blueshield NenyPolicy N/A

Sunosi (solriamfetol) prior authorization form — coverage criteria

Form and clinical questionnaire governing prior authorization requests for Sunosi (solriamfetol) tablets for members; used by providers to document diagnosis, prior medication trials, sleep study data, and treatment response for Highmark BlueShield NE/NY regions.

Policy Summary

PayerHighmark Blueshield Neny

PolicySunosi (solriamfetol) prior authorization form — coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the Sunosi prior authorization form with clinical documentation (diagnosis/ICD-10, sleep study data, ESS/MSLT/MWT results, and medication history) and fax or mail to Clinical Services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Sunosi strengths offered on form

30/90day supply selection

3condition worksheets included

2submission methods listed

Coverage Criteria and Requirements

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Form-based coverage criteria

Coverage requests require completion of all applicable sections and documentation demonstrating prior treatment trials, diagnostic test results, and ongoing benefit for reauthorization.

General submission: Form completed with member, provider, requested drug strength/quantity, diagnosis/ICD-10, and physician signature; submitted via fax or mail.

see form submission and certification language

Prior medication history: Documentation that the member experienced therapeutic failure, intolerance, or contraindication to generic modafinil; generic armodafinil; and a generic CNS stimulant (for example, dextroamphetamine or methylphenidate), or documentation of other medications tried and failed.

based on Medication History section

If treating obstructive sleep apnea (OSA): Document current/compliant PAP use or intolerance to PAP; status of oral appliance use; persistent daytime sleepiness despite adequate OSA treatment; confirmation that alternative causes of daytime sleepiness have been excluded; and provide diagnostic polysomnography metrics (AHI and RDI).

see OSA worksheet

If treating narcolepsy: Provide baseline daytime sleepiness measures (ESS and/or MWT), MSLT results including mean sleep latency and number of SOREMPs, PSG SOREMP count, hypocretin-1 CSF level and reference range if available, and document presence or absence of cataplexy.

see Narcolepsy worksheet

Reauthorization: For reauthorization, document that the member is currently on the requested therapy and that there has been improvement in daytime sleepiness or improvement on ESS or MWT compared to baseline.

see Reauthorization section

When Sunosi (solriamfetol) is being requested for treatment of obstructive sleep apnea (OSA), the prior authorization form requires the provider to confirm that alternative causes of daytime sleepiness have been excluded. This confirmation is captured directly on the OSA section of the form (question 5) alongside documentation of PAP or oral appliance use, persistent sleepiness despite adequate OSA treatment, and diagnostic polysomnography metrics such as AHI and RDI.

Providers should note that authorization does not guarantee payment. The form includes an explicit certification stating that payment is subject to member eligibility, and incomplete, unsupported, or otherwise insufficient documentation may result in non-payment or denial of the claim.

Provider Submission Requirements and Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for Sunosi. Providers must complete the prior authorization form and submit it with requested drug strength/quantity, diagnosis/ICD-10 code(s), and supporting clinical documentation.

Requested drug and strength (75 mg or 150 mg) and requested quantity/day supply
Diagnosis and ICD-10 code(s)
Payment is subject to member eligibility; authorization does not guarantee payment

Step Therapy

Required Prior Medication Trials

Documentation must show therapeutic failure, contraindication, or intolerance to required prior medications as indicated on the form.

Trial and failure, contraindication, or intolerance to generic modafinil
Trial and failure, contraindication, or intolerance to generic armodafinil
Trial and failure, contraindication, or intolerance to a generic CNS stimulant (e.g., dextroamphetamine, methylphenidate)
Any other medications tried and failed (provide details)

Documentation Required

Form Completion and Clinical Documentation

The provider must complete and submit the Sunosi prior authorization form and include all relevant clinical documentation.

Completed prior authorization form with medication history and response
Sleep disorder diagnostic data as applicable: polysomnography results (AHI, RDI), MSLT results (mean sleep latency, SOREMPs), ESS or MWT scores
For obstructive sleep apnea: documentation of PAP or oral appliance use and compliance, exclusion of alternative causes of sleepiness, and symptom checklist
For narcolepsy: baseline ESS/MWT, MSLT results, polysomnography details, hypocretin-1 level if available, and cataplexy status
Fax the completed form and clinical documentation to 1-866-240-8123 or mail to Clinical Services, 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222

Documentation Required

Reauthorization and Certification

Reauthorization: indicate whether the member is currently on therapy and document clinical response (improvement in daytime sleepiness or ESS/MWT compared to baseline). The submitting provider certifies accuracy of information.

Is the member currently on therapy with Sunosi? (Yes/No)
If yes, document improvement in daytime sleepiness and/or ESS or MWT compared to baseline
The submitting provider certifies that information is true, accurate, and complete
Note: Payment is subject to member eligibility; authorization does not guarantee payment

Clinical Definitions and Abbreviations

SOREMP (sleep-onset REM period)

SOREMP definition fieldNumber of sleep-onset rapid eye movement periods (SOREMPs) — numeric entry requested on MSLT and PSG sections

MSLT SOREMPsForm requests 'Number of sleep-onset rapid eye movement periods (SOREMPs)' from the MSLT results

PSG SOREMPsForm requests 'Number of sleep-onset rapid eye movement periods (SOREMPs)' from diagnostic polysomnography

Epworth Sleepiness Scale (ESS)

ESS fieldExcessive daytime sleepiness via the Epworth Sleepiness Scale (ESS) — numeric entry requested as baseline data

Use for narcolepsy baselineForm asks for ESS score as baseline EDS measurement when treating narcolepsy

Comparison for reauthorizationESS used to document improvement compared to baseline for reauthorization requests

Maintenance of Wakefulness Test (MWT)

MWT fieldExcessive daytime sleepiness via the Maintenance of Wakefulness Test (MWT) — numeric entry requested as baseline data

Use in narcolepsy assessmentForm requests MWT result as part of baseline EDS evaluation for narcolepsy

Reauthorization useMWT can be used to document improvement in daytime sleepiness for reauthorization

Apnea/Hypopnea Index (AHI)

AHI fieldApnea/hypopnea index (AHI) in events/hour — numeric entry requested from diagnostic polysomnography

RDI paired metricRespiratory disturbance index (RDI) in events/hour also requested alongside AHI

Context of useAHI requested when medication is used to treat obstructive sleep apnea to document severity and support ongoing daytime sleepiness assessment