CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Insomnia Belsomra Dayvigo Quviviq Pa With Limit Policy 1177 C Udr 01 2024

Prior authorization with quantity limits for Belsomra (suvorexant), Dayvigo (lemborexant), and Quviviq (daridorexant) for treatment of adult insomnia characterized by difficulties with sleep onset and/or sleep maintenance. Includes initial and continuation criteria, quantity limits, and duration of approval.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyInsomnia Belsomra Dayvigo Quviviq Pa With Limit Policy 1177 C Udr 01 2024

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrior authorization required for Belsomra, Dayvigo, and Quviviq per the specified initial and continuation criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes noted in this brief.

3Drugs covered

30 tablets / 25 days30-day qty-limit (fill equiv)

90 tablets / 75 days90-day qty-limit (fill equiv)

6 monthsInitial DOA

12 monthsContinuation DOA

Coverage Summary

Prior authorization with quantity limits is required for Belsomra (suvorexant), Dayvigo (lemborexant), and Quviviq (daridorexant) for treatment of adult insomnia characterized by difficulties with sleep onset and/or sleep maintenance. The policy includes specific initial and continuation criteria, applies quantity limits of 30 tablets per 25 days (30-day fill equivalent) or 90 tablets per 75 days (90-day fill equivalent), and sets the duration of approval at initial DOA: 6 months and continuation DOA: 12 months.

Initial Authorization - Insomnia (sleep onset and/or maintenance)

Initial Authorization - Insomnia with sleep onset and/or maintenance difficulties

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:

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Continuation (Renewal) Authorization Criteria

Continuation (Renewal) Authorization

Authorization may be granted for continuation when ALL of the following criteria are met:

Continuation requirements

Positive response: The patient has achieved or maintained a positive response to treatment from baseline
Assessment of need: The patient's need for continued therapy has been assessed
Address contributing factors/comorbidities: Potential factors contributing to sleep disturbances continue to be addressed (e.g., inappropriate sleep hygiene, sleep environment issues, treatable medical/psychiatric comorbid disorders)

Applicable Codes

Drug products covered by this policymixedCovered

Belsomra	suvorexant (brand name referenced)
Dayvigo	lemborexant (brand name referenced)
Quviviq	daridorexant (brand name referenced)

Provider Actions & Billing Rules

Prior Authorization

Prior authorization required

Prior authorization is required for Belsomra (suvorexant), Dayvigo (lemborexant), and Quviviq (daridorexant) and is granted only when the specified initial or continuation criteria for insomnia with difficulties in sleep onset and/or sleep maintenance are met.

Documentation Required

Document prior trials/intolerances/contraindications

For patients under 65 years of age, document an inadequate response, intolerance, or a contraindication to a generic non-benzodiazepine sedative-hypnotic (e.g., eszopiclone, zaleplon, zolpidem) or a benzodiazepine (e.g., temazepam) as applicable; contraindications must preclude trial of those agents.

Background & Clinical Evidence

Belsomra (suvorexant), Dayvigo (lemborexant), and Quviviq (daridorexant) are orexin receptor antagonists indicated for adults with insomnia characterized by difficulties with sleep onset and/or sleep maintenance. The policy aligns coverage to prior trials of generic non‑benzodiazepine sedative‑hypnotics or benzodiazepines for patients <65 and requires that potential contributing factors (e.g., sleep hygiene, sleep environment) and treatable medical/psychiatric comorbidities be addressed or be in the process of being addressed.

References include package inserts for Belsomra (February 2023), Dayvigo (May 2023), and Quviviq (October 2023), and cited clinical guidelines/databases such as the American Academy of Sleep Medicine (AASM) guidelines, Lexicomp, Micromedex, and the American Geriatrics Society Beers Criteria.

Policy thresholds & durations

Standard quantity-limit (30-day fill equivalent)30 tablets / 25 days

90-day quantity-limit (90-day fill equivalent)90 tablets / 75 days

Initial duration of approvalInitial DOA 6 months

Definitions

Non‑benzodiazepine sedative‑hypnotic: examples cited include eszopiclone, zaleplon, zolpidem.

OpenPayer

Insomnia Belsomra Dayvigo Quviviq Pa With Limit Policy 1177 C Udr 01 2024

Coverage Summary

Initial Authorization - Insomnia (sleep onset and/or maintenance)

Continuation (Renewal) Authorization Criteria

Applicable Codes

Provider Actions & Billing Rules

Background & Clinical Evidence

Definitions

Revision History