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Sunosi — Blue Cross Blue Shield of New Mexico

Excessive daytime sleepiness associated with narcolepsy

Preferred products

  • armodafinil
  • modafinil

Initial criteria

  • One of the following:
  • 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., 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. Both of the following:
  • 1. One of the following:
  • A. The patient has been diagnosed with stage IV advanced, metastatic cancer and the requested agent is being used to treat the cancer OR
  • B. The patient has been diagnosed with stage IV advanced, metastatic cancer and the requested agent is being used to treat an associated condition related to stage IV advanced metastatic cancer AND
  • 2. The use of the requested agent is consistent with best practices for the treatment of stage IV advanced, metastatic cancer, or an associated condition; supported by peer-reviewed, evidence-based literature; and approved by the FDA OR
  • B. The patient is currently being treated with and is stable on the requested agent 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/effectiveness, diminished effect, or an adverse event OR
  • E. The patient has 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, cause adherence barrier, worsen comorbid condition, 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 prescription drug in the same pharmacologic class or mechanism as armodafinil OR modafinil and it was discontinued due to lack of efficacy or adverse event
  • B. Diagnosis of excessive daytime sleepiness associated with narcolepsy AND one of the following:
  • 1. Both of the following:
  • A. One of the following regarding stage IV advanced metastatic cancer as above AND
  • B. The use is consistent with best practices, supported literature, and FDA approval OR
  • 2. The patient is currently being treated with and stable on the requested agent OR
  • 3. The patient has tried and had inadequate response to armodafinil OR modafinil OR
  • 4. Armodafinil OR modafinil discontinued due to lack of efficacy or adverse event OR
  • 5. The patient has intolerance or hypersensitivity to armodafinil OR modafinil OR
  • 6. The patient has an FDA-labeled contraindication to both armodafinil AND modafinil OR
  • 7. Armodafinil OR modafinil expected to be ineffective, cause adherence barrier, worsen comorbid condition, reduce function, or cause harm OR
  • 8. Armodafinil OR modafinil not in best interest based on medical necessity OR
  • 9. The patient has tried another drug in the same pharmacologic class or mechanism as armodafinil OR modafinil and discontinued due to lack of efficacy or adverse event
  • The patient has been evaluated using polysomnography and/or Multiple Sleep Latency Test AND
  • If FDA-labeled indication, then one of the following:
  • A. The patient’s age is within FDA labeling for requested indication OR
  • B. There is support for use in the patient’s age for the requested indication AND
  • The prescriber is a specialist (neurologist, psychiatrist, pulmonologist, or sleep disorder specialist) or has consulted with such specialist 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 diagnosis is excessive daytime sleepiness associated with OSA, underlying airway obstruction therapies (e.g., CPAP) will be continued during treatment AND
  • The prescriber is a specialist or has consulted 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