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.

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Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria Carveout
‐ Bill FFS
New Drug Evaluation & Updates
melatonin MELATONIN TABLET Y Pharmacy PA N  
ramelteon ROZEREM TABLET Y Pharmacy PA N  
daridorexant HCl QUVIVIQ TABLET N Pharmacy PA N  
diphenhydramine HCl SLEEP-AID CAPSULE N Pharmacy PA N  
diphenhydramine HCl SLEEP AID CAPSULE N Pharmacy PA N  
diphenhydramine HCl EZZ NITE SLEEP AID LIQUID N Pharmacy PA N  
diphenhydramine HCl SLEEP TABS TABLET N Pharmacy PA N  
diphenhydramine HCl NIGHTTIME SLEEP AID TABLET N Pharmacy PA N  
diphenhydramine HCl SLEEP AID TABLET N Pharmacy PA N  
doxylamine succinate SLEEP AID TABLET N Pharmacy PA N  
doxylamine succinate SLEEP AID ULTRA TABLET N Pharmacy PA N  
eszopiclone ESZOPICLONE TABLET N Pharmacy PA N  
midazolam HCl MIDAZOLAM HCL SYRUP N Pharmacy PA N  
quazepam DORAL TABLET N Pharmacy PA N  
quazepam QUAZEPAM TABLET N Pharmacy PA N  
tasimelteon HETLIOZ LQ ORAL SUSP N Pharmacy PA N  
temazepam RESTORIL CAPSULE N Pharmacy PA N  
triazolam HALCION TABLET N Pharmacy PA N  
zaleplon ZALEPLON CAPSULE N Pharmacy PA N  
zolpidem tartrate ZOLPIDEM TARTRATE ER TAB MPHASE N Pharmacy PA N Mar 27, 2014
zolpidem tartrate AMBIEN CR TAB MPHASE N Pharmacy PA N Mar 27, 2014
zolpidem tartrate ZOLPIDEM TARTRATE TAB SUBL N Pharmacy PA N Mar 27, 2014
melatonin/magnesium citrate SLOWMAG MG CALM-SLEEP TABLET DR Pharmacy PA N