CurrentNeighborhood Health Plan of Rhode IslandPolicy 2915-C

Sunosi (solriamfetol) prior authorization for excessive daytime sleepiness

This policy governs prior authorization and coverage criteria for Sunosi (solriamfetol) for adults with excessive daytime sleepiness due to narcolepsy or obstructive sleep apnea (OSA) for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySunosi (solriamfetol) prior authorization for excessive daytime sleepiness

Policy CodePolicy 2915-C

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and document sleep specialist involvement, diagnostic sleep study confirmation, required prior trial of armodafinil or modafinil (or intolerance/contraindication), and CPAP/BIPAP use for OSA as applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Narcolepsy; OSAindications covered

12 monthsduration of approval

30/25 • 90/75quantity limits

Sleep specialistspecialist requirement

Coverage Criteria for Sunosi (solriamfetol)

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Initial authorization — Narcolepsy

Covered when ALL of the following are met

Narcolepsy initial authorization

Prescriber and diagnosis: Prescribed by or in consultation with a sleep specialist AND diagnosis confirmed by sleep study.
Prior agent requirement: Inadequate response to armodafinil or modafinil OR intolerance to armodafinil or modafinil OR contraindication to trial of both armodafinil and modafinil.

Initial authorization — Obstructive Sleep Apnea (OSA)

Covered when ALL of the following are met

OSA initial authorization

Prescriber, diagnosis, and PAP use: Prescribed by or in consultation with a sleep specialist AND diagnosis confirmed by polysomnography or HSAT with a technically adequate device AND at least one month of CPAP/BIPAP prior to initiation AND planned continued use of CPAP/BIPAP.
Prior agent requirement: Inadequate response to armodafinil or modafinil OR intolerance to armodafinil or modafinil OR contraindication to trial of both armodafinil and modafinil.

Continuation — Narcolepsy

Covered when the following is met

Narcolepsy continuation: The patient has achieved or maintained a decrease in daytime sleepiness from baseline while on Sunosi.

Continuation — OSA

Covered when ALL of the following are met

OSA continuation: The patient has achieved or maintained a decrease in daytime sleepiness from baseline AND is compliant with CPAP or BIPAP use.

Sunosi (solriamfetol) is not indicated to treat the underlying airway obstruction in obstructive sleep apnea (OSA). The airway obstruction should be managed with appropriate modalities (for example, continuous positive airway pressure [CPAP] or bilevel positive airway pressure [BIPAP]) and those therapies are the primary treatments for the obstruction. Sunosi is intended to address excessive daytime sleepiness secondary to OSA, but it is not a substitute for therapies that treat the airway obstruction itself.

Authorization for Sunosi in patients with OSA requires evidence that the underlying airway obstruction has been treated with CPAP or BIPAP for at least one month prior to initiating Sunosi, and that those PAP therapies will be continued after Sunosi is started. Use of Sunosi without documentation of at least one month of prior CPAP/BIPAP treatment (and without planned continued PAP use) does not meet the stated criteria for authorization.

Prior Authorization, Documentation, and Step Therapy

Prior Authorization

Prior authorization required

Prior authorization is required and may be granted when all specified clinical criteria are met. Quantity limits apply: 30 tablets per 25 days or 90 tablets per 75 days. Duration of approval: 12 months.

Quantity limits: 30 tablets per 25 days or 90 tablets per 75 days
Duration of Approval (DOA): 12 months

Step Therapy

Step therapy requirement

A trial of armodafinil or modafinil is required prior to approval unless the patient has documented intolerance or a contraindication that precludes use of both agents.

Step therapy: inadequate response to armodafinil OR modafinil, OR documented intolerance to armodafinil OR modafinil, OR contraindication to both agents

Documentation Required

Document that a sleep specialist prescribed or was consulted

Requests must document that the requested medication is being prescribed by, or was prescribed in consultation with, a sleep specialist, and include objective confirmation of diagnosis (sleep study: polysomnography or HSAT for OSA; sleep study confirmation for narcolepsy).

Prescriber is a sleep specialist or consultation documented
Narcolepsy: diagnosis confirmed by sleep study
OSA: diagnosis confirmed by polysomnography or home sleep apnea test (HSAT) with a technically adequate device

Denial Risk

Documentation missing may trigger denial

Requests lacking documentation that the prescriber is a sleep specialist (or that a sleep specialist was consulted), or lacking confirmation of diagnosis (required sleep study/HSAT documentation) may be denied.

Missing sleep specialist prescriber or consultation note may result in denial
Missing sleep study/HSAT confirmation of diagnosis may result in denial

Denial Risk

OSA-specific CPAP/BIPAP treatment requirement

For OSA, documentation must show the patient has used CPAP or BIPAP for at least one month prior to the request and will continue to use CPAP/BIPAP after initiation of the requested drug; failure to document at least one month of treatment and ongoing use after initiation may trigger denial.

At least one month of CPAP/BIPAP treatment documented prior to approval
Ongoing CPAP/BIPAP use after medication initiation must be documented

Key Definitions

Sunosi (solriamfetol) — indication and limitations

IndicationImprove wakefulness in adults with excessive daytime sleepiness associated with narcolepsy or obstructive sleep apnea (OSA)

Not a treatment for airway obstructionSunosi is not indicated to treat the underlying airway obstruction in OSA and is not a substitute for therapies such as CPAP/BIPAP

Treatment context for OSAEnsure underlying airway obstruction is treated (e.g., CPAP) for at least one month prior to initiating Sunosi and continued during treatment

Technically adequate HSAT or polysomnography

DefinitionTechnically adequate HSAT or polysomnography: a home sleep apnea test (HSAT) or in-laboratory polysomnography that confirms the diagnosis of OSA using a technically adequate device

Authorization requirementDiagnosis of OSA must be confirmed by polysomnography or HSAT with a technically adequate device for prior authorization

Associated documentationDocumentation of the sleep study results must be provided as part of the authorization request

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySunosi (solriamfetol) prior authorization for excessive daytime sleepiness

Policy CodePolicy 2915-C

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

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Sunosi (solriamfetol) prior authorization for excessive daytime sleepiness

Coverage Criteria for Sunosi (solriamfetol)

Drug and Quantity Coding

Prior Authorization, Documentation, and Step Therapy

Key Definitions

Background