CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Authorization criteria for Belsomra, Dayvigo, and Quviviq for insomnia

Policy governs prior authorization, continuation, quantity limits, and coverage duration for Belsomra, Dayvigo, and Quviviq for members with insomnia disorder under the payer's Medicaid scope. It affects prescribers and pharmacy benefit adjudication for members age 18 and older.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAuthorization criteria for Belsomra, Dayvigo, and Quviviq for insomnia

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2022

Next Review DateN/A

Key ActionObtain and document a DSM‑V diagnosis of insomnia, verify member is ≥18, address contributing factors/comorbidities, and confirm failure/intolerance/contraindication to at least three formulary alternatives (or document applicable exception) when requesting prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=18minimum member age

3formulary alternatives required

1/dayquantity limit

12 mocoverage duration

28-day claim

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Coverage and Medical Necessity Criteria

inv-01: Initial Authorization

Covered when ALL of the following are met:

Initial Authorization Criteria: A. The member has a DSM‑V diagnosis of insomnia disorder (difficulty with sleep onset or sleep maintenance).

Initial Authorization Criteria: B. Member is at least 18 years of age.

Initial Authorization Criteria: C. Potential contributing factors to sleep disturbances (e.g., inappropriate sleep hygiene, sleep environment) and treatable medical/psychiatric comorbidities have been addressed or are currently being addressed.

Initial Authorization Criteria

D.1–D.3: 1. Inadequate treatment response, intolerance, or contraindication to at least three formulary alternatives (e.g., zolpidem, eszopiclone, zaleplon, trazodone, temazepam).
D.1–D.3: 2. Documented history of substance use disorder or current treatment for addiction making most formulary alternatives inappropriate.
D.1–D.3: 3. Provider is a sleep specialist with documented rationale and supporting documentation for not prescribing a formulary alternative.

Initial Authorization Criteria: E. If requesting Quviviq, the member has also experienced an inadequate treatment response, intolerance, or contraindication to Dayvigo or Belsomra.

inv-02: Continuation Therapy

Continuation of therapy — criteria (any of the following):

Continuation Criteria: At least one paid claim for a ≥28‑day supply of Belsomra, Dayvigo, or Quviviq within the last 365 days.

Continuation Criteria: Member meets all initial authorization criteria and has documentation of a positive clinical response, demonstrated by improvement in sleep onset and/or sleep maintenance.

There are no separate exclusion sections in this policy beyond the explicit criteria. However, coverage is limited to adults: members must be at least 18 years of age to meet the age requirement for approval. Other situations that effectively exclude coverage are failure to meet the required diagnostic or treatment criteria (for example, absence of a DSM‑V diagnosis of insomnia or lack of required trials of formulary alternatives), or missing documentation that contributing factors and treatable comorbid medical/psychiatric conditions have been addressed or are being addressed.

Use is considered not medically necessary when the initial authorization criteria are not satisfied. Examples include: no documented DSM‑V diagnosis of insomnia disorder, the member is younger than 18 years of age, inadequate documentation of attempts (or documented intolerance/contraindication) to at least three formulary alternatives when required, or lack of documentation that contributing factors (such as sleep hygiene/environment) and treatable medical or psychiatric comorbidities have been addressed or are being managed.

Requested Drugs, Claims Thresholds, and Quantity Limits

Referenced medicationsmixed

Belsomra	suvorexant (referenced as Belsomra in policy)
Dayvigo	lemborexant (referenced as Dayvigo in policy)
Quviviq	daridorexant (referenced as Quviviq in policy)
zolpidem	example formulary alternative
eszopiclone	example formulary alternative
zaleplon	example formulary alternative
trazodone	example formulary alternative
temazepam	example formulary alternative

Referenced medications - package inserts (references)mixed

Belsomra [package insert]	Merck Sharp & Dohme Corp.; March 2025 (policy reference)
Dayvigo [package insert]	Eisai; February 2025 (policy reference)
Quviviq [package insert]	Idorsia Pharmaceuticals US Inc.; October 2024 (policy reference)

Continuing therapy claim threshold — inv-06

ThresholdAt least one paid claim for a ≥28‑day supply of Belsomra, Dayvigo, or Quviviq within the last 365 days

Alternate continuation optionMember meets all initial authorization criteria AND documentation of positive clinical response (improved sleep onset and/or maintenance)

Look‑back period365 days from request date

Applies toBelsomra, Dayvigo, and Quviviq

Prior Authorization, Step Therapy, and Documentation Requirements

Prior Authorization

Prior authorization and continuation requirements

Prior authorization is required and will be granted only when all initial criteria are met (DSM‑V insomnia diagnosis, member ≥18 years, contributing factors/comorbidities addressed or being addressed) and one of the allowed exceptions under criterion D is satisfied; continuation may be approved if there is at least one paid claim for a ≥28‑day supply in the last 365 days or documentation of a positive clinical response.

Initial approval requires meeting criteria A–E in the policy.
Continuation can be met by recent paid claim (≥28‑day supply) or documented clinical improvement.

Step Therapy

Step therapy: trial of ≥3 formulary alternatives required

Members must have an inadequate response, intolerance, or contraindication to at least three formulary alternatives (examples: zolpidem, eszopiclone, zaleplon, trazodone, temazepam) unless an exception applies (documented substance use disorder or sleep‑specialist justification).

Clinical Background

Insomnia disorder, as used in this policy, refers to difficulty with sleep onset or sleep maintenance consistent with the DSM‑V. Management considerations that inform coverage decisions include evaluation and documentation of contributing factors such as sleep hygiene and sleep environment, and identification or treatment of co‑morbid medical or psychiatric conditions that may be causing or worsening insomnia. Prior authorization for orexin receptor antagonists requires confirmation of the diagnosis, adult age, addressing of contributing factors/comorbidities, and meeting step‑therapy or exception criteria described in the authorization rules.

Key Definitions

Insomnia disorder — inv-12

Core DSM‑V definitionInsomnia disorder: difficulty with sleep onset or sleep maintenance as characterized by the DSM‑V

Clinical implicationDiagnosis of insomnia disorder is required for authorization (see initial criteria)

Age noteDiagnosis must be in a member who is at least 18 years of age to meet policy criteria

Orexin Receptor Antagonists and Other Insomnia Medications

inv-13: Orexin receptor antagonists and other insomnia medications

Medication-specific rules: Belsomra, Dayvigo, and Quviviq are subject to the initial authorization criteria (DSM‑V diagnosis, ≥18 years, addressing contributing factors/comorbidities) and the step-therapy requirement (inadequate response/intolerance/contraindication to ≥3 formulary alternatives unless exception applies). Continuation requires either at least one paid claim of a ≥28‑day supply within the last 365 days or documentation of clinical improvement. Quantity limit: 1 tablet per day. Coverage duration: 12 months.