Sunosi — Blue Cross Blue Shield of Illinois

Preferred products

• armodafinil
• modafinil

Initial criteria

• ONE of the following: (A) 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
• • The modalities to treat the underlying airway obstruction (e.g., CPAP) will be continued during treatment with the requested agent
• • ONE of the following: (A) BOTH of the following: (1) The patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer OR the associated condition related to metastatic cancer; AND (2) The use of the requested agent is consistent with best practices and FDA-approved
• OR (B) The patient is currently being treated with the requested agent and is currently stable on it
• OR (C) The patient has tried and had an inadequate response to armodafinil OR modafinil
• OR (D) Armodafinil OR modafinil was discontinued due to lack of efficacy, diminished effect, or an adverse event
• OR (E) The patient has an intolerance or hypersensitivity to armodafinil OR modafinil
• OR (F) The patient has an FDA labeled contraindication to BOTH armodafinil AND modafinil
• OR (G) Armodafinil OR modafinil is expected to be ineffective based on known patient and drug characteristics; OR cause adherence barriers; OR worsen comorbidity; OR reduce functional ability; OR cause harm
• OR (H) Armodafinil OR modafinil is not in the best interest of the patient based on medical necessity
• OR (I) The patient has tried another drug in the same pharmacologic class or mechanism as armodafinil OR modafinil that was discontinued due to lack of efficacy or adverse event.
• OR (B) The patient has a diagnosis of excessive daytime sleepiness associated with narcolepsy AND ONE of the following:
• • Same criteria options (A–I) as for OSA diagnoses.
• Additionally: The patient has been evaluated using polysomnography and/or a Multiple Sleep Latency Test
• If the patient has an FDA labeled indication, then ONE of the following: (A) The patient’s age is within FDA labeling for that indication OR (B) There is support for age-appropriate use
• The prescriber is a specialist in the patient’s diagnosis area (neurologist, psychiatrist, pulmonologist, sleep disorder specialist) or has consulted one
• 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
• The patient has had clinical benefit with the requested agent
• If the diagnosis is excessive daytime sleepiness associated with OSA, CPAP or other modalities continue during treatment
• The prescriber is a specialist in the diagnosis area or has consulted one
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months