Agents for Hypersomnolence
PDL Reference Documents
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.
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 & Updates |
|---|---|---|---|---|---|
| armodafinil | ARMODAFINIL | TABLET | Y | PA Document | |
| armodafinil | NUVIGIL | TABLET | Y | PA Document | Sep 24, 2015 |
| modafinil | PROVIGIL | TABLET | Y | PA Document | Sep 24, 2015 |
| modafinil | MODAFINIL | TABLET | Y | PA Document | Sep 24, 2015 |
| solriamfetol HCl | SUNOSI | TABLET | V | PA Document | Jul 25, 2019 |
| pitolisant HCl | WAKIX | TABLET | N | PA Document | |
| sodium oxybate | XYREM | SOLUTION | N | Jul 25, 2019 | |
| sodium oxybate | SODIUM OXYBATE | SOLUTION | N | ||
| sodium,calcium,mag,pot oxybate | XYWAV | SOLUTION | N | ||
| armodafinil | NUVIGIL | TABLET | PA Document | Sep 24, 2015 | |
| modafinil | PROVIGIL | TABLET | PA Document | Sep 24, 2015 |