Sunosi — Blue Cross Blue Shield of Alabama

Preferred products

• armodafinil
• modafinil

Initial criteria

• ONE of the following:
• • The patient has a diagnosis of excessive daytime sleepiness associated with obstructive sleep apnea (OSA) AND ALL of the following:
• - The underlying airway obstruction has been treated (e.g., continuous positive airway pressure [CPAP]) for at least 1 month prior to initiating therapy with the requested agent AND
• - The modalities to treat the underlying airway obstruction (e.g., continuous positive airway pressure [CPAP]) will be continued during treatment with the requested agent AND
• - ONE of the following:
• ▪ The patient has tried and had an inadequate response with armodafinil OR modafinil OR
• ▪ The patient has an intolerance or hypersensitivity to armodafinil OR modafinil OR
• ▪ The patient has an FDA labeled contraindication to BOTH armodafinil AND modafinil
• OR
• • The patient has a diagnosis of excessive daytime sleepiness associated with narcolepsy AND ONE of the following:
• - The patient has tried and had an inadequate response with armodafinil OR modafinil OR
• - The patient has an intolerance or hypersensitivity to armodafinil OR modafinil OR
• - The patient has an FDA labeled contraindication to BOTH armodafinil AND modafinil
• AND
• • If the patient has an FDA labeled indication, then ONE of the following:
• - The patient’s age is within FDA labeling for the requested indication for the requested agent OR
• - There is support for using the requested agent for the patient’s age for the requested indication AND
• • The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist, psychiatrist, pulmonologist, sleep disorder specialist) or has consulted with a specialist in the area of the patient’s diagnosis AND
• • The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• • The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
• • The patient has had clinical benefit with the requested agent AND
• • If the diagnosis is excessive daytime sleepiness associated with obstructive sleep apnea (OSA), the modalities to treat the underlying airway obstruction (e.g., continuous positive airway pressure [CPAP]) will be continued during treatment with the requested agent AND
• • The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist, psychiatrist, pulmonologist, sleep disorder specialist) or has consulted with a specialist in the area of the patient’s diagnosis AND
• • The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months