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Insomnia Agents Quantity Limit Program Summary
Policy Number: PH-1049
This program applies to Commercial, Blue Partner, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace
POLICY REVIEW CYCLE
Effective Date |
Date of Origin |
07-01-2024 |
|
FDA LABELED INDICATIONS AND DOSAGE
See package insert for FDA prescribing information: https://dailymed.nlm.nih.gov/dailymed/index.cfm
POLICY AGENT SUMMARY QUANTITY LIMIT
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
QL Amount |
Dose Form |
Day Supply |
Duration |
Addtl QL Info |
Allowed Exceptions |
Targeted NDCs When Exclusions Exist |
|
|||||||||
|
zaleplon cap |
10 MG ; 5 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|
zolpidem tartrate cap |
7.5 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|
Zolpidem Tartrate SL Tab 1.75 MG |
1.75 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Zolpidem Tartrate SL Tab 3.5 MG |
3.5 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Ambien |
zolpidem tartrate tab |
10 MG ; 5 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Ambien cr |
zolpidem tartrate tab er |
12.5 MG ; 6.25 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Belsomra |
suvorexant tab |
10 MG ; 15 MG ; 20 MG ; 5 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Dayvigo |
lemborexant tab |
10 MG ; 5 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Edluar |
Zolpidem Tartrate SL Tab 10 MG |
10 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Edluar |
Zolpidem Tartrate SL Tab 5 MG |
5 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Lunesta |
eszopiclone tab |
1 MG ; 2 MG ; 3 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Quviviq |
daridorexant hcl tab |
25 MG ; 50 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Rozerem |
ramelteon tab |
8 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Silenor |
doxepin hcl (sleep) tab |
3 MG ; 6 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Zolpimist |
zolpidem tartrate oral spray |
5 MG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
CLIENT SUMMARY – QUANTITY LIMITS
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
|
zaleplon cap |
10 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
zolpidem tartrate cap |
7.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Zolpidem Tartrate SL Tab 1.75 MG |
1.75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Zolpidem Tartrate SL Tab 3.5 MG |
3.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ambien |
zolpidem tartrate tab |
10 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ambien cr |
zolpidem tartrate tab er |
12.5 MG ; 6.25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Belsomra |
suvorexant tab |
10 MG ; 15 MG ; 20 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Dayvigo |
lemborexant tab |
10 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Edluar |
Zolpidem Tartrate SL Tab 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Edluar |
Zolpidem Tartrate SL Tab 5 MG |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lunesta |
eszopiclone tab |
1 MG ; 2 MG ; 3 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Quviviq |
daridorexant hcl tab |
25 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Rozerem |
ramelteon tab |
8 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Silenor |
doxepin hcl (sleep) tab |
3 MG ; 6 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zolpimist |
zolpidem tartrate oral spray |
5 MG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL
Module |
Clinical Criteria for Approval |
|
Quantity Limit for the Target Agent(s) will be approved when ONE of the following is met:
Length of Approval: up to 12 months |
This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.
Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.
Commercial _ PS _ Insomnia_Agents_QL _ProgSum_ 07-01-2024