CurrentUnitedHealthcarePolicy N/A

Prior authorization form for solriamfetol (Sunosi) for excessive daytime sleepiness

Form used to request initial or continuation prior authorization for solriamfetol (Sunosi) for beneficiaries; collects beneficiary, prescriber, drug, and clinical information to determine coverage.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form for solriamfetol (Sunosi) for excessive daytime sleepiness

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProvider must submit the completed prior authorization form with drug details and attestations for initial or reauthorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

13clinical questions on form (includes continuation section)

30/60/90/120/180authorization length options (days)

18+age question included (adult eligibility checkpoint)

Coverage Criteria for Solriamfetol (Sunosi)

Initial Therapy

Covered when ALL of the following are met (provider must attest):

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form for solriamfetol (Sunosi) for excessive daytime sleepiness

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProvider must submit the completed prior authorization form with drug details and attestations for initial or reauthorization.

SourceLink

On This Page

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Initial eligibility: 1) Beneficiary is 18 years of age or older; 2) Adequate documented trial and failure of, or contraindication to, Provigil (modafinil) or Nuvigil (armodafinil); 3) Diagnosis of obstructive sleep apnea (OSA) or narcolepsy is documented on the form; 4) Beneficiary does not have end stage renal disease (eGFR < 15 ml/min/1.73m2); 5) Blood pressure has been assessed and hypertension is controlled (< 140/90 mmHg) prior to initiating treatment; 6) No MAO inhibitor use within the previous 14 days; 7) Provider documents whether beneficiary is receiving concomitant noradrenergic medications; 8) If treating OSA, provider attests beneficiary is compliant with and will continue using positive airway pressure (PAP) and prescriber has excluded other identifiable causes of sleepiness

All items are presented as yes/no attestations on the prior authorization form.

Continuation Therapy

Continued coverage considered when ALL of the following are met (provider must attest):

Continuation criteria: 1) Beneficiary has not developed increased blood pressure or heart rate that was not controlled by dose reduction of solriamfetol or medical intervention; 2) Documented reduction in excessive daytime sleepiness from pre-treatment baseline as measured by a validated scale (e.g., Epworth Sleepiness Scale, Stanford Sleepiness Scale, Karolinska Sleepiness Scale, Cleveland Adolescent Sleepiness Questionnaire, or Visual Analog Scale)

Provider must complete continuation questions 12-13 on the form and sign attestation.

The form lists several contraindications and conditions that, if present or not met, may render solriamfetol therapy not medically necessary. These include: lack of an adequate documented trial and failure of, or documented contraindication to, Provigil or Nuvigil (provider must answer and explain if contraindicated); uncontrolled hypertension prior to initiation (the form requires blood pressure assessed and controlled at 140/90 mmHg before starting); use of a monoamine oxidase (MAO) inhibitor within the previous 14 days; concomitant noradrenergic medications; noncompliance with positive airway pressure (PAP) when treating OSA; and failure to demonstrate improvement in daytime sleepiness for continuation. Providers must attest to these items on the form.

Initial Authorization Criteria

Initial authorization

Prescriber must provide drug details and attest to baseline clinical criteria:

Initial authorization: Provide drug name, strength, quantity per 30 days, and requested length of therapy; confirm beneficiary is >= 18 years; document prior trial and failure of, or contraindication to, Provigil or Nuvigil; indicate diagnosis (OSA or narcolepsy); confirm blood pressure assessed and controlled (<140/90 mmHg) prior to initiating; attest no MAO inhibitor within past 14 days; identify concomitant noradrenergic medications; if treating OSA attest to PAP compliance and exclusion of other causes of sleepiness

Drug name/strength/quantity/length fields and clinical questions 1-11 on the form capture these items; prescriber signature is required.

Reauthorization / Continuation Requirements

Reauthorization requirements

Reauthorization requires safety and efficacy attestations:

Reauthorization: 1) No uncontrolled increase in blood pressure or heart rate attributable to solriamfetol that was not managed by dose reduction or medical intervention; 2) Documented reduction in excessive daytime sleepiness from pre-treatment baseline on a validated scale

Questions 12-13 on the continuation section of the form capture these requirements; prescriber signature certifies accuracy.

Provider Submission Requirements and Risks

Prior Authorization

Prior Authorization Required

Prior authorization is required. The provider must submit a completed prior authorization form that specifies the drug name, strength, quantity per 30 days, length of therapy (selecting initial authorization or reauthorization interval), and indicate whether the request is for initial authorization or reauthorization.

Include selection for Initial Authorization or Reauthorization and choose appropriate duration (up to 30, 60, 90 days for initial; up to 30, 60, 90, 120, 180 days for reauthorization).
Provide Prescribing Provider NPI and requester contact name/phone.
Provide beneficiary identifiers (name, beneficiary ID, date of birth, gender).

Documentation Required

Required Documentation on Form

The form requires documentation of beneficiary demographics, prescriber NPI and contact information, drug name/strength/quantity, length of therapy, and responses to all clinical questions. The prescriber must sign and date the form (prescriber signature is mandatory).

Beneficiary last name, first name, beneficiary ID, date of birth, gender.
Prescribing provider NPI and requester contact information (name, phone, ext).
Drug name, strength, quantity per 30 days, and selected length of therapy.
Responses to all clinical questions and prescriber signature with date.

Step Therapy

Step Therapy: Provigil / Nuvigil

Step therapy applies: the form asks whether the beneficiary had an adequate trial and failure of, or a documented contraindication to, Provigil (modafinil) or Nuvigil (armodafinil). A negative response (no trial/failure or no contraindication) may preclude coverage per step-therapy rules.

Indicate Yes/No to: documented trial and failure of, or contraindication to, Provigil or Nuvigil.
If contraindicated, provide explanation on the form.

Denial Risk

Triggers for Potential Denial

Incomplete or adverse clinical responses on the form may trigger denial. Missing required attestations, absent prescriber signature, age under 18 when adult-only criteria required, no documented trial/failure of Provigil or Nuvigil, uncontrolled hypertension, end stage renal disease (eGFR < 15 ml/min/1.73 m2), recent MAOI use (within 14 days), or other negative eligibility answers are triggers for potential denial.

Missing prescriber signature or missing responses to required clinical questions.
Beneficiary age < 18 when policy requires ≥18.
No documented trial/failure of Provigil or Nuvigil (and no contraindication).
Uncontrolled blood pressure (not < 140/90 mmHg) or new uncontrolled hypertension/heart rate on treatment.
End stage renal disease (eGFR < 15 ml/min/1.73 m2).
MAO inhibitor use within previous 14 days.
Noncompliance with PAP when treating OSA or failure to exclude other causes of sleepiness.

Step	Requirement
1	Must document an adequate trial and failure of, or a contraindication to, Provigil (modafinil) or Nuvigil (armodafinil). Form asks provider to indicate Yes/No and to explain if contraindicated.

Definitions and Clinical Terms

inv-11: eGFR < 15 ml/min/1.73m2 — definition: End stage renal disease

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

Form fieldQuestion 5 on the clinical information form asks whether beneficiary has eGFR < 15 ml/min/1.73m2

Policy implicationPresence of ESRD (eGFR <15) is identified as a contraindicating condition to be reported and may preclude coverage

inv-12: Attestation that beneficiary is compliant with and will continue using PAP (for OSA) — definition of PAP compliance

Definition of PAP compliance attestationProvider must attest that if treating OSA, the beneficiary is compliant with and will continue using positive airway pressure (PAP)

Form fieldQuestion 10 on the clinical information form captures the provider's attestation of PAP compliance (Yes/No)

Associated requirementIf treating OSA, prescriber must also exclude other identifiable causes of sleepiness (Question 11)

Background

Solriamfetol (Sunosi) is a wake‑promoting agent used to treat excessive daytime sleepiness associated with narcolepsy or obstructive sleep apnea (OSA). The prior authorization form collects baseline safety and efficacy checkpoints relevant to solriamfetol prescribing, including age (≥18), prior treatment trials with Provigil/Nuvigil or documented contraindication, blood pressure assessment and control, recent MAOI use, renal function (ESRD), PAP compliance for OSA, and—on reauthorization—documentation of reduced daytime sleepiness on a validated scale and absence of uncontrolled increases in blood pressure or heart rate attributable to therapy.

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