CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Prior Authorization Criteria — Insomnia Agents (suvorexant, lemborexant, daridorexant)

Defines prior authorization requirements, coverage criteria, quantity limits, and approval durations for Belsomra (suvorexant), Dayvigo (lemborexant), and Quviviq (daridorexant) for treatment of adult insomnia. Affects prescribers and pharmacy benefit adjudication for members covered by the payer.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPrior Authorization Criteria — Insomnia Agents (suvorexant, lemborexant, daridorexant)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document trials or contraindications to required comparator agents and assessment of contributing factors to insomnia.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3drugs covered

6m / 12mapproval duration (init/cont)

3030-day qty limit

9090-day qty limit

Coverage Criteria for Orexin Receptor Antagonists

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inv-01: Initial therapy — Covered when ALL of the following are met

Covered when ALL of the following are met:

Indication: Requested drug is prescribed for treatment of insomnia characterized by difficulties with sleep onset and/or sleep maintenance.

Age and prior therapy: Either the patient is 65 years of age or older OR if less than 65, the patient has experienced an inadequate response to OR intolerance of BOTH: A) a generic non‑benzodiazepine sedative‑hypnotic (eszopiclone, zaleplon, zolpidem), and B) a benzodiazepine (e.g., temazepam).

Trials can be bypassed if the patient has a contraindication to all listed trials.

Supportive assessments: Potential factors contributing to sleep disturbances (e.g., inappropriate sleep hygiene, sleep environment issues, treatable medical/psychiatric comorbidities) have been addressed or are currently being addressed.

inv-02: Continuation therapy — Covered when ALL of the following are met

Continuation therapy covered when ALL of the following are met:

Continuation request: Request is for continuation of therapy.

Clinical benefit: Patient has achieved or maintained a positive response to treatment from baseline.

Ongoing assessment: Need for continued therapy has been assessed and potential contributing factors to sleep disturbances continue to be addressed (e.g., inappropriate sleep hygiene, sleep environment issues, treatable medical/psychiatric comorbidities).

Duration of approval for continuation: 12 months.

When evaluating requests that do not clearly meet the initial therapy criteria (for example, submissions that are not labelled as continuation or lack documentation of prior trials), the request will be assessed against the continuation therapy criteria. If the request is not a continuation and the documentation does not satisfy the initial therapy requirements, the request would not meet coverage criteria as written and is at risk for denial. Providers should therefore explicitly indicate whether the request is for continuation and supply the documentation required for either initial or continuation authorization.

Initial Therapy Requirements

inv-10: Initial therapy criteria — structured requirements and trials for initiation

Initial therapy requirements and trials

Not continuation: Request is NOT for continuation of therapy.

Assessment of contributing factors: Potential factors contributing to sleep disturbances have been addressed or are being addressed (e.g., sleep hygiene, sleep environment, treatable medical/psychiatric comorbidities).

Age or prior therapy requirement: Either the patient is >= 65 years of age OR (if <65) the patient has experienced an inadequate response to OR intolerance of BOTH: A) a generic non‑benzodiazepine sedative‑hypnotic (eszopiclone, zaleplon, zolpidem) and B) a benzodiazepine (e.g., temazepam).

Trials may be omitted if the patient has a contraindication to all listed agents.

Continuation of Therapy Requirements

inv-11: Continuation criteria — requirements for ongoing approval

Continuation of therapy requirements

Continuation request: Request is for continuation of therapy.

Positive response maintained: Patient has achieved or maintained a positive response to treatment from baseline.

Assessment and duration: Prescriber has assessed need for continued therapy and potential contributing factors to sleep disturbances continue to be addressed.

Duration of approval for continuation: 12 months.

Prescriber and Pharmacy Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for coverage of Belsomra, Dayvigo, and Quviviq for insomnia. Requests that do not meet the coverage criteria risk denial.

Applicable products: Belsomra, Dayvigo, Quviviq
Prior authorization required before benefit is applied

Step Therapy

Step Therapy / Trials Required

Step therapy trials are required for patients under 65 years of age. The patient must have had inadequate response or intolerance to the specified first-line agents, unless a documented contraindication prevents trials.

Required trials for patients < 65 years: A) a generic non‑benzodiazepine sedative‑hypnotic (e.g., eszopiclone, zaleplon, zolpidem) AND B) a benzodiazepine (e.g., temazepam) — trial must show inadequate response or intolerance
If the patient has a contraindication to ALL of the agents above, step therapy may be bypassed

Documentation Required

Documentation for Quantity / Continuation

Requests for continuation of therapy require documentation of ongoing benefit and reassessment of need. Quantity limits and treatment duration rules apply; document assessment and ongoing management of contributing factors.

For continuation: document that the patient has achieved or maintained a positive response from baseline and that need for continued therapy was assessed
Quantity limits: 30 tablets per 25 days (for a 30‑day fill) or 90 tablets per 75 days (for a 90‑day fill)
Re-evaluate and document addressing of contributing factors (sleep hygiene, sleep environment, treatable medical/psychiatric comorbidities)

Denial Risk

Coverage Criteria Required — Risk of Denial if Not Met

Coverage is granted only when all coverage criteria are met. Incomplete documentation or failure to meet criteria (including required trials for patients <65, lack of contraindication documentation, or missing reassessment for continuation) may result in denial.

Covered indication: insomnia with difficulties initiating and/or maintaining sleep
Requests for continuation of therapy must meet continuation criteria to avoid denial
Failure to show prior trials, contraindication, or assessment of ongoing benefit risks denial

Step Therapy Requirements

Required trial / exception	Details
Trials required	For patients <65 years: inadequate response to OR intolerance of BOTH: A) a generic non‑benzodiazepine sedative‑hypnotic (e.g., eszopiclone, zaleplon, zolpidem) AND B) a benzodiazepine (e.g., temazepam).
Age exception	Patients 65 years of age or older are exempt from the two‑class trial requirement (meeting age criterion satisfies prior‑therapy requirement).
Contraindication exception	If the patient has a contraindication that would prohibit trial of ALL agents in both classes (non‑benzodiazepine sedative‑hypnotic and benzodiazepine), trials may be bypassed.
Continuation requests	Requests that are for continuation of therapy require documentation of positive response/benefit and ongoing assessment; continuation is considered separately from initial‑therapy trial requirements.

Definitions and Indications

Insomnia (drug indication) — definition

DefinitionInsomnia characterized by difficulties with sleep onset and/or sleep maintenance as stated in product indications for Belsomra, Dayvigo, and Quviviq.

ScopeApplies to adult patients for whom one of the listed orexin receptor antagonists is prescribed, per the product indications.

Clinical contextTreatment decisions should consider addressing contributing factors (e.g., sleep hygiene, sleep environment, treatable medical or psychiatric comorbidities).