Agents for Hypersomnolence

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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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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Current Drug Use Criteria
00093309256 ARMODAFINIL armodafinil TABLET 150 mg Y Y PA Document
00378343293 ARMODAFINIL armodafinil TABLET 150 mg Y Y PA Document
00781803731 ARMODAFINIL armodafinil TABLET 150 mg Y Y PA Document
65862080630 ARMODAFINIL armodafinil TABLET 150 mg Y Y PA Document
60505484703 NUVIGIL armodafinil TABLET 150 mg Y PA Document
63459021530 NUVIGIL armodafinil TABLET 150 mg Y Y PA Document
00093309356 ARMODAFINIL armodafinil TABLET 200 mg Y Y PA Document
00781804531 ARMODAFINIL armodafinil TABLET 200 mg Y Y PA Document
65862099830 ARMODAFINIL armodafinil TABLET 200 mg Y Y PA Document
69339017903 ARMODAFINIL armodafinil TABLET 200 mg Y Y PA Document
60505484903 NUVIGIL armodafinil TABLET 200 mg Y PA Document
63459022030 NUVIGIL armodafinil TABLET 200 mg Y Y PA Document
00093309456 ARMODAFINIL armodafinil TABLET 250 mg Y Y PA Document
00378343393 ARMODAFINIL armodafinil TABLET 250 mg Y Y PA Document
00781805331 ARMODAFINIL armodafinil TABLET 250 mg Y Y PA Document
65862080730 ARMODAFINIL armodafinil TABLET 250 mg Y Y PA Document
60505485003 NUVIGIL armodafinil TABLET 250 mg Y PA Document
63459022530 NUVIGIL armodafinil TABLET 250 mg Y Y PA Document
00093309056 ARMODAFINIL armodafinil TABLET 50 mg Y Y PA Document
00378343193 ARMODAFINIL armodafinil TABLET 50 mg Y Y PA Document
00781802931 ARMODAFINIL armodafinil TABLET 50 mg Y Y PA Document
65862080530 ARMODAFINIL armodafinil TABLET 50 mg Y Y PA Document
69339017703 ARMODAFINIL armodafinil TABLET 50 mg Y Y PA Document
60505484603 NUVIGIL armodafinil TABLET 50 mg Y PA Document
63459020530 NUVIGIL armodafinil TABLET 50 mg Y Y PA Document
00904679104 MODAFINIL modafinil TABLET 100 mg Y Y PA Document
23155060403 MODAFINIL modafinil TABLET 100 mg Y Y PA Document
23155060409 MODAFINIL modafinil TABLET 100 mg Y Y PA Document
50268057011 MODAFINIL modafinil TABLET 100 mg Y Y PA Document
50268057012 MODAFINIL modafinil TABLET 100 mg Y Y PA Document
55253080130 MODAFINIL modafinil TABLET 100 mg Y Y PA Document
57237015430 MODAFINIL modafinil TABLET 100 mg Y Y PA Document
57237015490 MODAFINIL modafinil TABLET 100 mg Y Y PA Document
60505252601 MODAFINIL modafinil TABLET 100 mg Y Y PA Document
60505252603 MODAFINIL modafinil TABLET 100 mg Y Y PA Document
62332038530 MODAFINIL modafinil TABLET 100 mg Y Y PA Document
62332038590 MODAFINIL modafinil TABLET 100 mg Y Y PA Document
65862060101 MODAFINIL modafinil TABLET 100 mg Y Y PA Document
65862060130 MODAFINIL modafinil TABLET 100 mg Y Y PA Document
68084062111 MODAFINIL modafinil TABLET 100 mg Y Y PA Document
68084062121 MODAFINIL modafinil TABLET 100 mg Y Y PA Document
69452034213 MODAFINIL modafinil TABLET 100 mg Y Y PA Document
72578000506 MODAFINIL modafinil TABLET 100 mg Y Y PA Document
72578000516 MODAFINIL modafinil TABLET 100 mg Y Y PA Document
60505485103 PROVIGIL modafinil TABLET 100 mg Y PA Document
63459010130 PROVIGIL modafinil TABLET 100 mg Y Y PA Document
00904679204 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
23155060503 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
23155060509 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
23155086203 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
23155086209 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
50268057111 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
50268057112 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
55253080230 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
55253080290 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
57237015530 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
57237015590 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
60505252701 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
60505252703 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
62332038630 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
62332038690 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
65862060201 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
65862060230 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
68084072111 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
68084072121 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
69452034313 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
69452034319 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
72578000601 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
72578000606 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
72578000616 MODAFINIL modafinil TABLET 200 mg Y Y PA Document
60505485203 PROVIGIL modafinil TABLET 200 mg Y PA Document
63459020130 PROVIGIL modafinil TABLET 200 mg Y Y PA Document
72028017803 WAKIX pitolisant HCl TABLET 17.8 mg N Y PA Document
72028004503 WAKIX pitolisant HCl TABLET 4.45 mg N Y PA Document
00054962857 SODIUM OXYBATE sodium oxybate SOLUTION 500 mg/mL N Y  
69238239101 SODIUM OXYBATE sodium oxybate SOLUTION 500 mg/mL N Y  
68727010001 XYREM sodium oxybate SOLUTION 500 mg/mL N Y  
68727015001 XYWAV sodium,calcium,mag,pot oxybate SOLUTION 0.5 gram/mL N Y  
81968035101 SUNOSI solriamfetol HCl TABLET 150 mg V Y PA Document
81968035107 SUNOSI solriamfetol HCl TABLET 150 mg V Y PA Document
81968035110 SUNOSI solriamfetol HCl TABLET 150 mg V Y PA Document
81968035001 SUNOSI solriamfetol HCl TABLET 75 mg V Y PA Document
81968035007 SUNOSI solriamfetol HCl TABLET 75 mg V Y PA Document
81968035010 SUNOSI solriamfetol HCl TABLET 75 mg V Y PA Document
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