solriamfetol hcl — Blue Cross Blue Shield of Kansas

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: (1) 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 (2) The modalities to treat the underlying airway obstruction (e.g., CPAP) will be continued during treatment with the requested agent AND (3) ONE of the following: (A) The patient has tried and had an inadequate response with armodafinil OR modafinil OR (B) The patient has an intolerance or hypersensitivity to armodafinil OR modafinil OR (C) The patient has an FDA labeled contraindication to BOTH armodafinil AND modafinil
• (B) The patient has a diagnosis of excessive daytime sleepiness associated with narcolepsy AND ONE of the following: (1) The patient has tried and had an inadequate response with armodafinil OR modafinil OR (2) The patient has an intolerance or hypersensitivity to armodafinil OR modafinil OR (3) The patient has an FDA labeled contraindication to BOTH armodafinil AND modafinil
• If the patient has an FDA labeled indication, then ONE of the following: (A) The patient’s age is within FDA labeling for the requested indication OR (B) There is support for using the requested agent for the patient’s age for the requested indication
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist, psychiatrist, pulmonologist, sleep disorder specialist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
• 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 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
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist, psychiatrist, pulmonologist, sleep disorder specialist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months