CurrentUnitedHealthcarePolicy N/A

Prior authorization form and coverage criteria for solriamfetol (Sunosi) and related wake‑promoting agents

This document is a pharmacy prior authorization form collecting beneficiary, prescriber, drug, and clinical information to determine coverage for solriamfetol (Sunosi) or similar wake‑promoting drugs for excessive daytime sleepiness due to narcolepsy or OSA. It is intended for prescribing providers and pharmacies submitting PA requests to UnitedHealthcare.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form and coverage criteria for solriamfetol (Sunosi) and related wake‑promoting agents

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form including beneficiary, prescriber, drug details, and clinical information confirming diagnosis, prior trial/failure of modafinil/armodafinil or contraindication, blood pressure assessment, MAOI avoidance, and documented improvement on a validated sleepiness scale for continuation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

13clinical questions on the form (including continuation criteria)

3administrative sections (beneficiary, prescriber, drug)

90 daystypical maximum initial authorization interval

14 daysMAOI exclusion lookback

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form and coverage criteria for solriamfetol (Sunosi) and related wake‑promoting agents

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Coverage Criteria

Initial Authorization

Covered when ALL of the following are met (per form).

Age: Beneficiary is 18 years of age or olderage >= 18

form question 1

Diagnosis of narcolepsy or obstructive sleep apnea (OSA)diagnosis = narcolepsy OR diagnosis = OSA

form questions 3-4

Prior trial or contraindication: Adequate documented trial and failure of, or contraindication to, Provigil (modafinil) or Nuvigil (armodafinil)trial_failed OR contraindication_documented

form question 2

Blood pressure assessment: Blood pressure assessed and hypertension controlled (< 140/90 mmHg) prior to initiating treatmentBP < 140/90

form question 6

MAOI exclusion: No monoamine oxidase inhibitor (MAOI) received within the previous 14 daysno_MAOI_within_14_days

form question 7

Concomitant medications: Provider documents whether beneficiary is receiving concomitant noradrenergic medicationsdocumented

form question 8

OSA-specific attestations: If treating OSA, provider attests beneficiary is PAP-compliant and other identifiable causes of sleepiness have been excludedPAP_compliant = yes AND other_causes_excluded = yes

form questions 10-11

Continuation of Therapy

Covered when ALL of the following continuation criteria are met.

Safety—vitals: Beneficiary has not developed increased blood pressure or heart rate that was not controlled by dose reduction or medical interventionno_uncontrolled_BP_or_HR

form question 12

Clinical benefit: Documented reduction in excessive daytime sleepiness from pre-treatment baseline measured by a validated scaledocumented_improvement_on_scale

form question 13

Use of a monoamine oxidase inhibitor (MAOI) within the previous 14 days prior to initiating therapy is an exclusionary safety condition and is asked directly on the clinical questionnaire. Presence of MAOI exposure in that window would preclude approval unless the MAOI requirement is resolved.

The form requires documentation that the beneficiary has had an adequate trial and failure of, or a documented contraindication to, Provigil (modafinil) or Nuvigil (armodafinil). Treatment requests that do not include either a prior trial/failure or a documented contraindication to these preferred agents may be considered unsupported by the form and could be denied.

Initial Therapy Requirements

Initial therapy requires prescriber attestation and prior trial info

Initial therapy requires prescriber attestation and documentation of prior trial information.

Prescriber attestation: Prescriber signature attesting that the information provided is accurate and complete is submitted

Prescriber signature mandatory on form

Age verification: Attestation that beneficiary is 18 years of age or olderage >= 18

form question 1

Prior trial documentation: Documentation of an adequate trial and failure of, or documented contraindication to, Provigil (modafinil) or Nuvigil (armodafinil)

form question 2

Drug and treatment details: Completed drug information including drug name, strength, quantity per 30 days, and selected length of therapy

Drug information section on form

Continuation Requirements

Continuation requires safety and effectiveness documentation

Continuation requires documentation of safety and effectiveness.

Safety documentation: Documentation that beneficiary has not developed increased blood pressure or heart rate that was not controlled by dose reduction or medical intervention

form question 12

Effectiveness documentation: Documentation of reduced excessive daytime sleepiness from pre-treatment baseline measured by a validated scale (e.g., Epworth, Stanford, Karolinska, Cleveland Adolescent, or VAS)

form question 13

Provider Actions & Documentation

Prior Authorization

Prior Authorization Form Completion

Prior authorization requires completion of the prior authorization form. The form must include beneficiary demographics, prescriber NPI and contact information, drug name/strength/quantity, selected length of therapy, and answers to all applicable clinical questions on the form.

Beneficiary name, ID, DOB, and gender
Prescribing provider NPI and requester contact (name, phone, ext.)
Drug name, strength, quantity per 30 days, and selected length of therapy (initial or reauthorization)

Step Therapy

Prior Trial Requirement (Preferred Agent Trial)

An adequate documented trial and failure of, or a documented contraindication to, modafinil (Provigil) or armodafinil (Nuvigil) is required before approval. If the form does not indicate trial and failure or contraindication to these preferred agents, the request may be denied.

Question on form: “Does the beneficiary have an adequate documented trial and failure of, or contraindication to, Provigil or Nuvigil?” — must be answered
If contraindicated, provider must explain reason in the space provided

Documentation Required

Required Supporting Documentation

Required supporting documentation must accompany the PA request. Incomplete or missing documentation increases risk of denial or delay.

Completed beneficiary demographics (name, ID #, DOB, gender)
Prescriber NPI and requester contact information (name, phone, ext.)
Drug name, strength, quantity per 30 days, and selected length of therapy (initial or reauthorization option)
Answers to clinical questions (age ≥18, diagnoses such as narcolepsy or OSA, eGFR, blood pressure assessment/control, MAOI use in past 14 days, concomitant noradrenergic meds, preferred drug trial details, PAP compliance when treating OSA)
For continuation requests: documentation of response (validated sleepiness scale) and any blood pressure/heart rate issues

Denial Risk

MAOI Co-medication Exclusion

Use of a monoamine oxidase inhibitor (MAOI) within the previous 14 days is an exclusion. If the beneficiary has received an MAOI in the prior 14 days the request is likely to be denied.

Form question: “Has the beneficiary received an MAO inhibitor within the previous 14 days?” — must be answered
Answering “Yes” will generally preclude approval

Clinical Metrics & Coding

Validated improvement assessment

RequirementDocumented reduction in excessive daytime sleepiness from pre-treatment baseline as measured by a validated scale (e.g., Epworth, Stanford, Karolinska, Cleveland Adolescent Sleepiness Questionnaire, or Visual Analog Scale)

When requiredRequested on the continuation-of-therapy section and must be answered by the prescriber (form question 13)

PurposeDemonstrates clinical benefit of continued solriamfetol therapy

Blood pressure control

ThresholdBlood pressure assessed and hypertension controlled (< 140/90 mmHg) prior to initiating treatment

When askedDocumented on the initial-therapy clinical questionnaire (form question 6)

Clinical rationaleSolriamfetol carries cardiovascular monitoring considerations; BP control must be confirmed before initiation

Definitions

End stage renal disease

DefinitionEnd stage renal disease is defined on the form as estimated glomerular filtration rate (eGFR) < 15 ml/min/1.73 m2.

Form locationAsked on the clinical information section (form question 5)

ImplicationESRD is queried as a potential contraindication or safety consideration for therapy

Validated sleepiness scale

ExamplesEpworth Sleepiness Scale; Stanford Sleepiness Scale; Karolinska Sleepiness Scale; Cleveland Adolescent Sleepiness Questionnaire; Visual Analog Scale.

Use caseOne of these validated scales is used to document baseline and post-treatment sleepiness for continuation decisions (form question 13)

Requested on formContinuation-of-therapy section asks for documented reduction measured by a validated scale (form question 13)

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