Sunosi (solriamfetol) — Highmark
narcolepsy
Preferred products
- generic modafinil
- generic CNS stimulant (e.g., dextroamphetamine, methylphenidate)
Initial criteria
- age ≥ 18 years
- diagnosis of narcolepsy (ICD-10: G47.41)
- meets one of the following: (a) MSLT substantiating mean sleep latency ≤ 8 minutes AND ≥ 2 SOREMPs OR (b) polysomnography and MSLT substantiating mean sleep latency ≤ 8 minutes AND ≥1 SOREMP on each test OR (c) documented hypocretin-1 deficiency defined as cerebrospinal fluid hypocretin-1 <110 pg/mL or < one-third of normal value
- prescriber provides documentation of baseline ESS or MWT for excessive daytime sleepiness
- meets one of the following: (a) if narcolepsy with cataplexy, has therapeutic failure, contraindication, or intolerance to a generic CNS stimulant (e.g., dextroamphetamine) OR (b) if narcolepsy without cataplexy, has therapeutic failure, contraindication, or intolerance to all of the following: generic modafinil AND a generic CNS stimulant (e.g., dextroamphetamine, methylphenidate)
Reauthorization criteria
- prescriber attests member experienced a decrease in daytime sleepiness with improvement on ESS or MWT compared to baseline
Approval duration
12 months