Sedatives

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Drug Use Review Documents

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 but eligible patients will encounter a co-pay at the pharmacy.
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
ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE TABLET Y PA Document  
ZOLPIDEM TARTRATE AMBIEN TABLET Y PA Document  
DIPHENHYDRAMINE HCL Z-SLEEP CAPSULE N PA Document  
DIPHENHYDRAMINE HCL SLEEP TIME LIQUID N PA Document  
DIPHENHYDRAMINE HCL SLEEP AID TABLET N PA Document  
DIPHENHYDRAMINE HCL SLEEP TABS TABLET N PA Document  
DIPHENHYDRAMINE HCL NIGHTTIME SLEEP AID TABLET N PA Document  
DOXEPIN HCL SILENOR TABLET N PA Document  
DOXYLAMINE SUCCINATE SLEEP AID TABLET N PA Document  
ESTAZOLAM ESTAZOLAM TABLET N PA Document  
ESZOPICLONE ESZOPICLONE TABLET N PA Document  
ESZOPICLONE LUNESTA TABLET N PA Document  
FLURAZEPAM HCL FLURAZEPAM HCL CAPSULE N PA Document  
MIDAZOLAM HCL MIDAZOLAM HCL SYRUP N PA Document  
RAMELTEON ROZEREM TABLET N PA Document  
SUVOREXANT BELSOMRA TABLET N PA Document  
TASIMELTEON HETLIOZ CAPSULE N PA Document  
TEMAZEPAM TEMAZEPAM CAPSULE N PA Document  
TEMAZEPAM RESTORIL CAPSULE N PA Document  
TRIAZOLAM TRIAZOLAM TABLET N PA Document  
TRIAZOLAM HALCION TABLET N PA Document  
ZALEPLON SONATA CAPSULE N PA Document  
ZALEPLON ZALEPLON CAPSULE N PA Document  
ZOLPIDEM TARTRATE ZOLPIMIST SPRAY/PUMP N PA Document  
ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE ER TAB MPHASE N PA Document  
ZOLPIDEM TARTRATE AMBIEN CR TAB MPHASE N PA Document  
ZOLPIDEM TARTRATE INTERMEZZO TAB SUBL N PA Document  
ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE TAB SUBL N PA Document  
ZOLPIDEM TARTRATE EDLUAR TAB SUBL N PA Document