Sedative Hypnotics
Drug - Sedative Hypnotics
September 2016
Sedative hypnotics
Preferred
Nonpreferred
- Ambien (zolpidem) PA
- Ambien CR and zolpidem CR PA
- Belsomra PA
- Edluar (zolpidem sublingual) PA
- Intermezzo PA
- Lunesta PA
- Rozerem
- Sonata PA
- Zolpimist (zolpidem) PA
Prior authorization criteria
Lunesta
- Patient is 18 years of age or older AND
- Has a known intolerance to zolpidem OR
- Has a known ineffectiveness of zolpidem
Zolpimist (zolpidem) oral spray
- Patient is 18 years of age or older AND
- Cannot take a solid oral dosage form AND
- Is taking no other solid oral dosage forms
Intermezzo (zolpidem sublingual)
- Patient is 18 years of age or older AND
- Has tried and failed zaleplon AND zolpidem IR AND Lunesta AND
- Clinical documentation of insomnia characterized with ONLY middle-of-the-night awakenings
Edluar (zolpidem sublingual)
- Patient is 18 years of age or older
- Patient has demonstrated difficulty swallowing AND
- Is taking no other solid oral dosage forms
Zolpidem CR generic
- Patient is 18 years of age or older AND
- Has been shown to have a positive response to zolpidem AND
- Has failed Lunesta by ineffectiveness
Branded Ambien, Ambien CR; Belsomra
- Patient is 18 years of age or older
- Patient must fail by ineffectiveness or intolerance zolpidem and zaleplon and Lunesta AND
- For brand name Ambien CR, the patient meets the brand name drug criteria
Quantity limits on sedative hypnotics
- Ambien CR brand and generic (6.25 mg, 12.5 mg) - 34 tablets
- zolpidem generic (5 mg, 10 mg) - 5 mg - 34 tablets, 10 mg - 68 tablets
- Ambien (5 mg, 10 mg) - 5 mg - 34 tablets, 10 mg - 68 tablets
- Belsomra (5 mg, 10 mg, 15 mg, 20 mg) - 34 tablets - any strength
- Lunesta (1 mg, 2 mg, 3 mg) - 34 tablets - any strength
- Sonata (5 mg, 10 mg) - 5 mg - 34 capsules, 10 mg - 68 capsules
- Rozerem (8 mg) - 34 tablets (not subject to PA)
- Edluar (5 mg, 10 mg) - 34 tablets
- Intermezzo - 34 tablets
Questions?
MHCP Provider Call Center 651-431-2700 or 800-366-5411