CurrentUnitedHealthcarePolicy N/A

Sunosi (solriamfetol) prior authorization

Defines UnitedHealthcare prior authorization and reauthorization requirements for Sunosi (solriamfetol) for adults with excessive daytime sleepiness due to narcolepsy or obstructive sleep apnea (OSA). Applies to pharmacy benefit management and prescribers requesting coverage.

Policy Summary

PayerUnitedHealthcare

PolicySunosi (solriamfetol) prior authorization

Policy CodePolicy N/A

Change TypeOperational revision

Effective DateNov 16, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document diagnosis (sleep study or justification) and, for OSA, ≥1 month of compliant airway therapy before requesting Sunosi.

SourceLink

POLICY UPDATE CHANGES

Updated initial authorization duration to 12 months.

12 monthsauthorization period

narcolepsy, OSAindications covered

CPAP ≥1 morequired airway therapy

7 datesP&T review history

Coverage Criteria for Sunosi (solriamfetol)

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Initial Therapy — Narcolepsy

Covered when ALL of the following are met

Narcolepsy initial: (1) Diagnosis of narcolepsy as confirmed by sleep study (unless the prescriber provides justification that a sleep study is not feasible); AND (2) Symptoms of excessive daytime sleepiness (e.g., daily periods of irrepressible need to sleep or daytime lapses into sleep) are present.

Authorization issued for 12 months

Reauthorization — Narcolepsy

Covered when ALL of the following are met

Narcolepsy reauth: (1) Reduction in symptoms of excessive daytime sleepiness associated with Sunosi (solriamfetol) therapy.

Authorization issued for 12 months

Initial Therapy — Obstructive Sleep Apnea (OSA)

Covered when ALL of the following are met

OSA initial: (1) Diagnosis of obstructive sleep apnea as confirmed by sleep study (unless the prescriber provides justification that a sleep study is not feasible); AND (2) Both of the following: i) Standard treatments for the underlying airway obstruction (e.g., CPAP, BiPAP) have been used for one month or longer, and ii) Patient is fully compliant with ongoing treatment(s) for the underlying airway obstruction.>= 1 month for prior airway therapy

Authorization issued for 12 months

Reauthorization — Obstructive Sleep Apnea (OSA)

Covered when ALL of the following are met

OSA reauth: (1) Reduction in symptoms of excessive daytime sleepiness associated with Sunosi (solriamfetol) therapy; AND (2) Patient continues to be fully compliant with ongoing treatment(s) for the underlying airway obstruction (e.g., CPAP, BiPAP).

Authorization issued for 12 months

Sunosi is not indicated to treat the underlying airway obstruction in obstructive sleep apnea (OSA) and is not a substitute for airway obstruction therapies such as continuous positive airway pressure (CPAP). Providers must ensure that standard airway obstruction treatment has been used and is continued while prescribing Sunosi; for OSA this includes at least 1 month of airway therapy prior to initiating Sunosi.

Coding and Therapy Duration Details

Required duration of airway obstruction therapy prior to Sunosi

Required duration>= 1 month of standard airway obstruction therapy (e.g., CPAP, BiPAP) prior to initiating Sunosi

Compliance requirementPatient must be fully compliant with ongoing airway obstruction treatment at time of Sunosi initiation

ContinuationAirway obstruction modalities should be continued during Sunosi therapy

Standard OSA airway therapies (examples and role)

ExamplesContinuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP)

PurposeStandard treatments to address underlying airway obstruction in OSA prior to considering adjunctive wakefulness therapy

Treatment period guidanceThese modalities should be used for at least one month before initiating Sunosi

Ongoing useAirway obstruction therapies should be continued during treatment with Sunosi; Sunosi is not a substitute for these therapies

Prescriber Requirements and Operational Notes

Prior Authorization

Prior Authorization Required

Prior authorization required. Initial approvals are issued when documentation shows diagnosis and treatment/compliance criteria for narcolepsy or obstructive sleep apnea (OSA) are met; authorizations are typically issued for 12 months.

Initial authorization duration: 12 months
Program-level automated approvals may occur based on prior claims/medication history and diagnosis codes; supply limits and medical necessity edits may apply

Documentation Required

Required Documentation

Documentation must be submitted to support the diagnosis and treatment history. At a minimum, include: confirmation of diagnosis by sleep study or a prescriber statement justifying why a sleep study was not feasible; documentation of symptoms of excessive daytime sleepiness when narcolepsy is the diagnosis; for OSA, documentation that standard airway obstruction therapies (e.g., CPAP, BiPAP) were used for ≥1 month and that the patient is compliant with ongoing therapy.

Diagnosis confirmation: sleep study report OR prescriber justification for infeasibility
Symptoms: documentation of excessive daytime sleepiness (e.g., irrepressible sleep, daytime lapses) — required for narcolepsy
OSA therapy history: evidence CPAP/BiPAP used ≥1 month
OSA compliance: documentation the patient is fully compliant with ongoing airway obstruction treatment

Denial Risk

Triggers for Denial

Denial may be triggered when required diagnostic or treatment documentation is absent or incomplete. Examples: no sleep study confirmation and no prescriber justification; for OSA, failure to document prior airway obstruction therapy for ≥1 month or lack of documentation of ongoing treatment compliance. Automated program rules may also deny requests based on claim history, diagnosis coding, supply limits, or medical necessity edits.

Missing sleep study confirmation with no prescriber justification — risk of denial
For OSA: no evidence of ≥1 month of CPAP/BiPAP use — risk of denial
For OSA: no documentation of continued treatment compliance — risk of denial
Automated denial possible based on prior claims/medication history, ICD-10 codes, supply limits, or medical necessity edits

Initial Authorization Criteria

Initial Therapy — Initial authorization criteria per indication

Initial authorization criteria per indication

Initial narcolepsy: Diagnosis of narcolepsy confirmed by sleep study (unless prescriber justifies infeasibility) AND symptoms of excessive daytime sleepiness are present.

Authorization for 12 months

Initial OSA: Diagnosis of obstructive sleep apnea confirmed by sleep study (unless prescriber justifies infeasibility) AND standard airway obstruction treatments (e.g., CPAP, BiPAP) have been used for >= 1 month AND patient is fully compliant with ongoing airway therapy.>= 1 month for prior airway therapy

Authorization for 12 months

Program action	Details
Program may use prior claim/medication history, diagnosis codes (ICD-10), and automated approval/re‑approval processes
Supply limits and medical necessity edits may apply; use of automated processes varies by program or therapeutic class

Background on Sunosi (solriamfetol)

Sunosi (solriamfetol) is a dopamine and norepinephrine reuptake inhibitor (DNRI) indicated to improve wakefulness in adults with excessive daytime sleepiness associated with narcolepsy or obstructive sleep apnea (OSA). Limitations of use include that Sunosi does not treat the underlying airway obstruction in OSA; standard airway therapies (for example, CPAP) should be used for at least 1 month before starting Sunosi and continued during Sunosi therapy.

Policy Summary

PayerUnitedHealthcare

PolicySunosi (solriamfetol) prior authorization

Policy CodePolicy N/A

Change TypeOperational revision

Effective DateNov 16, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document diagnosis (sleep study or justification) and, for OSA, ≥1 month of compliant airway therapy before requesting Sunosi.

SourceLink

On This Page

OpenPayer

Sunosi (solriamfetol) prior authorization

Coverage Criteria for Sunosi (solriamfetol)

Coding and Therapy Duration Details

Prescriber Requirements and Operational Notes

Initial Authorization Criteria

Reauthorization / Continuation Criteria

Step Therapy and Program Limits

Background on Sunosi (solriamfetol)