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Insomnia Agents Quantity Limit Program Summary

Policy Number: PH-91049

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:

  1. The requested quantity (dose) does NOT exceed the program quantity limit OR
  2. The requested quantity (dose) exceeds the program quantity limit AND ONE of the following:
    1. BOTH of the following:
      1. The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND
      2. There is support for therapy with a higher dose for the requested indication OR
    2. BOTH of the following:
      1. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
      2. There is support for why the requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit OR
    3. BOTH of the following:
      1. The requested quantity (dose) exceeds the maximum FDA labeled dose for the requested indication AND
      2. There is support for therapy with a higher dose for the requested indication

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