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 AMBIEN TABLET Y PA Document  
zolpidem tartrate ZOLPIDEM TARTRATE TABLET Y PA Document  
diphenhydramine HCl Z-SLEEP CAPSULE N PA Document  
diphenhydramine HCl SLEEP AID 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  
eszopiclone ESZOPICLONE TABLET N PA Document  
eszopiclone LUNESTA TABLET N PA Document  
ramelteon ROZEREM TABLET N PA Document  
suvorexant BELSOMRA TABLET N PA Document  
tasimelteon HETLIOZ CAPSULE N PA Document  
zaleplon ZALEPLON CAPSULE N PA Document  
zaleplon SONATA 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