Sedatives

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
melatonin MELATONIN TABLET Y PA Document  
ramelteon RAMELTEON TABLET Y PA Document  
ramelteon ROZEREM TABLET Y PA Document  
zolpidem tartrate AMBIEN TABLET Y PA Document  
zolpidem tartrate ZOLPIDEM TARTRATE TABLET Y PA Document  
daridorexant HCl QUVIVIQ TABLET N PA Document  
diphenhydramine HCl NIGHTTIME SLEEP AID CAPSULE N PA Document  
diphenhydramine HCl SLEEP AID CAPSULE N PA Document  
diphenhydramine HCl SLEEP TIME CAPSULE N PA Document  
diphenhydramine HCl SLEEP-AID CAPSULE N PA Document  
diphenhydramine HCl SLEEP AID LIQUID N PA Document  
diphenhydramine HCl SLEEP TIME LIQUID N PA Document  
diphenhydramine HCl NIGHTTIME SLEEP AID TABLET N PA Document  
diphenhydramine HCl SLEEP AID TABLET N PA Document  
diphenhydramine HCl SLEEP TABS TABLET N PA Document  
doxepin HCl DOXEPIN HCL TABLET N PA Document  
doxylamine succinate SLEEP AID TABLET N PA Document  
estazolam ESTAZOLAM TABLET N PA Document  
eszopiclone LUNESTA TABLET N PA Document  
eszopiclone ESZOPICLONE TABLET N PA Document  
flurazepam HCl FLURAZEPAM HCL CAPSULE N PA Document  
lemborexant DAYVIGO TABLET N PA Document  
melatonin MELATONIN TAB RAPDIS N PA Document  
midazolam HCl MIDAZOLAM HCL SYRUP N PA Document  
quazepam QUAZEPAM TABLET N PA Document  
quazepam DORAL TABLET N PA Document  
suvorexant BELSOMRA TABLET N PA Document  
tasimelteon HETLIOZ CAPSULE N PA Document  
tasimelteon TASIMELTEON CAPSULE N PA Document  
tasimelteon HETLIOZ LQ ORAL SUSP N PA Document  
temazepam RESTORIL CAPSULE N PA Document  
temazepam TEMAZEPAM CAPSULE N PA Document  
triazolam TRIAZOLAM TABLET N PA Document  
triazolam HALCION TABLET N PA Document  
zaleplon ZALEPLON CAPSULE N PA Document  
zolpidem tartrate ZOLPIDEM TARTRATE CAPSULE N PA Document  
zolpidem tartrate ZOLPIDEM TARTRATE ER TAB MPHASE N PA Document  
zolpidem tartrate AMBIEN CR TAB MPHASE N PA Document  
zolpidem tartrate EDLUAR TAB SUBL N PA Document  
zolpidem tartrate ZOLPIDEM TARTRATE TAB SUBL N PA Document  
chloral hydrate CHLORAL HYDRATE SYRUP PA Document  
melatonin/magnesium citrate SLOWMAG MG CALM-SLEEP TABLET DR PA Document  
melatonin/pyridoxine HCl (B6) MELATONIN-VITAMIN B6 TABLET PA Document