Sedative Hypnotics

Drug - Sedative Hypnotics

September 2016

Sedative hypnotics

Preferred

zaleplon
zolpidem

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