CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Sunosi (solriamfetol) coverage for excessive daytime sleepiness

Policy covers Sunosi (solriamfetol) for adults (>=18 years) with excessive daytime sleepiness due to narcolepsy or obstructive sleep apnea (OSA) under specified prior-authorization clinical criteria; other indications are considered investigational/not covered. Scope: Medicaid.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySunosi (solriamfetol) coverage for excessive daytime sleepiness

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2020

Next Review DateN/A

Key ActionPrior authorization for Sunosi is required; authorizations may be granted for 12 months when clinical criteria (indication, specialist prescriber, documented trials/intolerance/contraindications, polysomnography for OSA, CPAP compliance) are met.

POLICY UPDATE CHANGES

No material clinical/coverage changes to policy.

2Covered indications

1 monthRequired CPAP/modafinil trial duration

12 monthsAuthorization duration

Coverage Summary

Sunosi (solriamfetol) is covered with prior authorization under this Medicaid policy for adults ≥18 years with excessive daytime sleepiness due to narcolepsy or obstructive sleep apnea (OSA) when specified clinical criteria are met (FDA‑approved indication, prescriber specialty, documented diagnostic confirmation, required prior therapies or documented intolerance/contraindication, and CPAP requirements for OSA). All other indications are considered experimental/investigational and are not covered.

Initial Therapy Criteria

Indications and General Requirement

Covered when ALL of the following are met:

ALL of the following

Indication is an FDA-approved indication: improve wakefulness in adult patients with excessive daytime sleepiness associated with narcolepsy or obstructive sleep apnea (OSA).
Member exclusions: Member has no exclusions to the prescribed therapy.
Prescriber specialty
- Prescriber specialty list
  - Neurologist
  - Sleep disorder specialist
  - Psychiatrist

ref": "b1_0

title": "Indications and General Requirement

ref": "b1_0"}

title":

A. Narcolepsy - Initial Authorization

Authorization of 12 months may be granted when ALL of the following are met:

ALL of the following

Age: Patient is 18 years of age or older.
Narcolepsy confirmation: Narcolepsy is confirmed by an evaluation (sleep evaluation).
Prior stimulant/modafinil criteria (ONE of)
- CNS stimulant trial/intolerance: Patient experienced an inadequate treatment response, intolerance, or contraindication to a central nervous system (CNS) stimulant (e.g., amphetamine/dextroamphetamine, methylphenidate).
- Modafinil/armodafinil specific

B. Obstructive Sleep Apnea (OSA) - Initial Authorization

Authorization of 12 months may be granted when ALL of the following are met:

ALL of the following

Age: Patient is 18 years of age or older.
OSA confirmation: OSA is confirmed by polysomnography.
CPAP trial and residual sleepiness: Patient has been receiving treatment for the underlying airway obstruction with continuous positive airway pressure (CPAP) for at least one month, with documented evidence of residual sleepiness despite compliance.>= 1 month
Prior pharmacotherapy criteria (ONE of)