CurrentUnitedHealthcarePolicy 2024 P 1285-6

Sunosi (solriamfetol) prior authorization policy

UnitedHealthcare prior authorization/notification policy defining clinical criteria for initial and reauthorization coverage of Sunosi (solriamfetol) for adults with excessive daytime sleepiness due to narcolepsy or obstructive sleep apnea, including treatment compliance requirements for OSA.

Policy Summary

PayerUnitedHealthcare

PolicySunosi (solriamfetol) prior authorization policy

Policy CodePolicy 2024 P 1285-6

Change TypeRevised (authorization duration)

Effective DateDec 1, 2024

Next Review Date

Key ActionSubmit prior authorization documenting diagnosis, sleep study or justification, and OSA treatment use/compliance; approvals issued for 12 months.

POLICY UPDATE CHANGES

Updated initial authorization to 12 months (9/2024).

Annual reference updates across prior reviews (7/2019, 7/2020, 8/2021, 9/2022, 11/2023).

2Covered indications

12 moAuthorization duration

>=1 moRequired OSA therapy prior to start

Coverage Summary

Initial Therapy Criteria

Initial Authorization — Narcolepsy

Sunosi will be approved based on all of the following criteria:

ALL of the following

Diagnosis of narcolepsy as confirmed by sleep study (unless the prescriber provides justification confirming that a sleep study would not be feasible)
Symptoms of excessive daytime sleepiness (including but not limited to daily periods of irrepressible need to sleep or daytime lapses into sleep) are present

Continuation / Reauthorization Criteria

Reauthorization — Narcolepsy

Sunosi will be approved for continuation of therapy based on the following criterion:

ALL of the following

Reduction in symptoms of excessive daytime sleepiness associated with Sunosi therapy

Provider Actions & Prior Authorization

Prior Authorization

Prior authorization required

Sunosi requires prior authorization/notification. Members must meet the listed diagnostic and treatment compliance criteria prior to approval. Authorization is issued for 12 months.

Documentation Required

Sleep study or justification

For narcolepsy and OSA, provide confirmation of diagnosis by sleep study or a prescriber justification that a sleep study is not feasible.

Documentation Required

OSA treatment compliance documentation

Document use of and full compliance with standard airway obstruction treatments (e.g., CPAP, BiPAP) for ≥1 month prior to initiating Sunosi and continued compliance for reauthorization.

Denial Risk

Denial risk if criteria not met

Claims may be denied if documentation does not support the diagnosis, prior sleep study (or prescriber justification), presence of excessive daytime sleepiness, reduction in symptoms on therapy for reauthorization, or documentation of OSA treatment compliance.

Billing Rule

Authorization duration

Approvals and reauthorizations are issued for 12 months.

Clinical Evidence & References

Reference - package insert: Sunosi [package insert], Axsome Therapeutics, Inc; June 2023.

Guideline: American Academy of Sleep Medicine clinical practice guideline for central disorders of hypersomnolence referenced.

Background & Definitions

Sunosi is a dopamine and norepinephrine reuptake inhibitor (DNRI) indicated to improve wakefulness in adult patients with excessive daytime sleepiness associated with narcolepsy or obstructive sleep apnea.

Sunosi is not indicated to treat the underlying airway obstruction. Ensure the underlying airway obstruction is treated (e.g., with continuous positive airway pressure [CPAP]) for at least one month prior to initiating Sunosi, and modalities to treat the underlying airway obstruction should be continued during treatment with Sunosi; Sunosi is not a substitute for these modalities.

Fully compliant: Member adheres to ongoing treatment(s) for underlying airway obstruction (e.g., CPAP, BiPAP) as documented by prescriber.

Revision History

9/2024material_changeLatest

Updated initial authorization duration to 12 months.

11/2023annual_review

Annual review — updated references.

9/2022annual_review

Annual review — updated references and added state mandate footnote.

8/2021annual_review

Annual review — updated references.

7/2020annual_review

Annual review — updated references.

7/2019annual_review

Program established (new prior authorization program).

Policy Summary

PayerUnitedHealthcare

PolicySunosi (solriamfetol) prior authorization policy

Policy CodePolicy 2024 P 1285-6

Change TypeRevised (authorization duration)

Effective DateDec 1, 2024

Next Review Date

Key ActionSubmit prior authorization documenting diagnosis, sleep study or justification, and OSA treatment use/compliance; approvals issued for 12 months.

On This Page

OpenPayer

Sunosi (solriamfetol) prior authorization policy

Coverage Summary

Initial Therapy Criteria

Continuation / Reauthorization Criteria

Provider Actions & Prior Authorization

Applicable Codes

Clinical Evidence & References

Background & Definitions

Revision History