CurrentNeighborhood Health Plan of Rhode IslandPolicy 1177-C

Insomnia Products: Dayvigo

Defines authorization (initial and continuation) criteria, quantity limits, and duration of approval for lemborexant (Dayvigo) and related orexin receptor antagonists for treatment of adult insomnia characterized by difficulties with sleep onset and/or sleep maintenance. Applies to listed branded and generic forms of suvorexant, lemborexant, and daridorexant.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyInsomnia Products: Dayvigo

Policy CodePolicy 1177-C

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization should document that sleep hygiene and treatable comorbid conditions have been addressed and that the patient meets age or prior-therapy criteria (age ≥65 OR age <65 with inadequate response, intolerance, or contraindication to specified generic sedative-hypnotics/benzodiazepines).

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical guidance or coverage were made.

3Drugs referenced (brand/generic)

30/25dStandard short-term quantity limit

90/75dStandard extended quantity limit

6 moInitial approval DOA

Coverage Summary

Coverage stance: covered_with_criteria for orexin receptor antagonists (lemborexant, suvorexant, daridorexant) for adult insomnia characterized by difficulties with sleep onset and/or sleep maintenance. Scope:

This policy (Policy Number 1177-C) defines initial and continuation authorization criteria, quantity limits, and duration of approval for the listed branded and generic forms of suvorexant (Belsomra), lemborexant (Dayvigo), and daridorexant (Quviviq).

Initial Authorization Criteria

Continuation Therapy Criteria

Continuation (Renewal) Authorization - Insomnia characterized by difficulties with sleep onset and/or sleep maintenance

Authorization may be granted when the requested drug is being prescribed for the treatment of insomnia characterized by difficulties with sleep onset and/or sleep maintenance when ALL of the following criteria are met:

ALL of the following

Potential factors contributing to sleep disturbances have been addressed or are currently being addressed (e.g., inappropriate sleep hygiene and sleep environment issues) as well as treatable medical/psychiatric disorders that are co-morbid with insomnia.
Patient age / prior therapy
- The patient is 65 years of age or older.
- Patient is <65 years and ONE of the following
  - The patient experienced an inadequate treatment response to ANY of the following: a generic non-benzodiazepine sedative-hypnotic (e.g., eszopiclone, zaleplon, zolpidem), a benzodiazepine (e.g., temazepam).
  - The patient experienced an intolerance to ANY of the following: a generic nonbenzodiazepine sedative-hypnotic (e.g., eszopiclone, zaleplon, zolpidem), a benzodiazepine (e.g., temazepam).
  - The patient has a contraindication that would prohibit a trial of ALL of the following: a generic non-benzodiazepine sedative-hypnotic (e.g., eszopiclone, zaleplon, zolpidem), a benzodiazepine (e.g., temazepam).

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title": "Initial Authorization - Insomnia characterized by difficulties with sleep onset and/or sleep maintenance"

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Applicable Codes

Referenced drugs (brand and generic)mixed

Belsomra	suvorexant (brand included)
Dayvigo	lemborexant (brand included)
Quviviq	daridorexant (brand included)

Provider Actions & Requirements

Prior Authorization

Prior authorization required with documented criteria

Prior authorization should document that sleep hygiene and treatable comorbid conditions have been addressed and that the patient meets age or prior-therapy criteria (age ≥65 OR age <65 with inadequate response, intolerance, or contraindication to specified generic sedative-hypnotics/benzodiazepines).

Documentation Required

Documentation of positive response for continuation

For continuation, document a positive response from baseline, assessment of need for continued therapy, and ongoing management of contributing factors to insomnia.

Clinical Evidence & References

Key references include package inserts: Belsomra (suvorexant) [package insert, 2023], Dayvigo (lemborexant) [package insert, 2023], and Quviviq (daridorexant) [package insert, 2024]; professional guidance including the American Academy of Sleep Medicine clinical practice guideline(s) and the 2023 American Geriatrics Society Beers Criteria. FDA package inserts and professional guidelines are referenced for clinical and safety guidance.

Background

Background: This policy covers orexin receptor antagonists (lemborexant, suvorexant, daridorexant) indicated for adult patients with insomnia characterized by difficulties with sleep onset and/or sleep maintenance. The policy emphasizes that potential contributing factors (for example, inappropriate sleep hygiene, sleep environment issues, and treatable medical or psychiatric comorbidities) should be addressed or are being addressed prior to or during pharmacologic therapy. The policy references FDA package inserts and professional guidelines for indications and clinical guidance.

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