CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Prior authorization criteria for Sunosi (solriamfetol) — narcolepsy agents

Prior authorization criteria and quantity limits for Sunosi (solriamfetol) to treat excessive daytime sleepiness in adults with narcolepsy or obstructive sleep apnea (OSA); applies to prescribers and pharmacy prior authorization reviewers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPrior authorization criteria for Sunosi (solriamfetol) — narcolepsy agents

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document diagnosis by polysomnography, trial or intolerance/contraindication to armodafinil or modafinil, and CPAP/BIPAP use for OSA.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 moDuration of approval

30/25dQty limit (30-day equiv)

90/75dQty limit (90-day equiv)

Coverage Criteria for Sunosi (solriamfetol)

Initial and continuation coverage criteria

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General indication: Patient has excessive daytime sleepiness associated with obstructive sleep apnea (OSA) or narcolepsy.

based on FDA indication

Prescriber and diagnosis confirmation: Requested drug is prescribed by or in consultation with a sleep specialist AND diagnosis confirmed by polysomnography or sleep lab evaluation.

OSA-specific airway therapy: For OSA: patient has been receiving treatment for underlying airway obstruction with CPAP or BIPAP for at least one month and will continue therapy.>=1 month

CPAP/BIPAP must be continued during Sunosi treatment

Prior stimulant therapy (initial requests): Patient has had an inadequate treatment response to armodafinil OR modafinil OR has experienced intolerance to armodafinil OR modafinil OR has a contraindication that would prohibit a trial of both armodafinil and modafinil.

Intolerance or contraindication can substitute for lack of trial

Continuation of therapy: For continuation: patient has achieved or maintained a decrease in daytime sleepiness from baseline and remains compliant with CPAP/BIPAP for OSA when applicable.

Continuation requests require documentation of benefit and adherence

Provider Requirements, Prior Authorization, and Step Therapy

Prior Authorization

Prior Authorization Required

Prior authorization required. Approvals are granted for 12 months when criteria are met. Quantity limits apply.

Step Therapy

Step Therapy Requirement

Step therapy requirement — documented inadequate response to armodafinil or modafinil is required unless there is documented intolerance or a contraindication to both agents.

Documentation Required

Documentation requirements — confirmatory sleep testing and prior treatment documentation are required. Provider must include documentation confirming the diagnosis (e.g., polysomnography or sleep lab evaluation), evidence of prior treatment for underlying airway obstruction (CPAP or BIPAP) with at least one month of use when applicable, and records documenting prior trials and inadequate response or intolerance/contraindication to armodafinil and/or modafinil.

Denial Risk

Denial Risk if Criteria Not Met

Denial conditions — requests may be denied if prior authorization criteria are not met (for example, lack of confirmed diagnosis, missing required documentation, failure to document prior therapy or trial of armodafinil/modafinil when required).

Definitions and Limitation of Use

inv-08: Drug identity — Sunosi (solriamfetol) indication summary

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

Target populationAdults with excessive daytime sleepiness due to narcolepsy or OSA.

Clinical useUsed to promote wakefulness; not a treatment for the underlying cause of OSA-related airway obstruction.

Prescriber contextPrescribed by or in consultation with a sleep specialist per coverage criteria.

inv-09: Limitation of use for OSA — not a substitute for treating underlying airway obstruction; recommend CPAP/BIPAP where appropriate.

Limitation of use (primary)Sunosi is not indicated to treat the underlying airway obstruction in OSA; it is not a substitute for modalities that treat obstruction (e.g., CPAP/BIPAP).

Required airway therapy before initiationUnderlying airway obstruction should be treated (for example, with CPAP) for at least one month prior to initiating Sunosi for OSA-related sleepiness.

Continuation of airway therapyModalities to treat the underlying airway obstruction should be continued during treatment with Sunosi.

Background

Sunosi is indicated to improve wakefulness in adults with excessive daytime sleepiness due to narcolepsy or OSA. For patients with OSA, the underlying airway obstruction must be treated and optimized (for example, with CPAP/BIPAP) for at least 1 month prior to initiating Sunosi, and those airway therapies should be continued while the patient receives Sunosi.