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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.
| 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 | RAMELTEON | TABLET | Y | Pharmacy PA | N | |
| ramelteon | ROZEREM | TABLET | Y | Pharmacy PA | N | |
| zolpidem tartrate | ZOLPIDEM TARTRATE | TABLET | Y | Pharmacy PA | N | Mar 27, 2014 |
| zolpidem tartrate | AMBIEN | TABLET | Y | Pharmacy PA | N | Mar 27, 2014 |
| daridorexant HCl | QUVIVIQ | TABLET | N | Pharmacy PA | N | |
| diphenhydramine HCl | NIGHTTIME SLEEP AID | CAPSULE | N | Pharmacy PA | N | |
| diphenhydramine HCl | SLEEP AID | CAPSULE | N | Pharmacy PA | N | |
| diphenhydramine HCl | SLEEP-AID | CAPSULE | N | Pharmacy PA | N | |
| diphenhydramine HCl | SLEEP TIME | LIQUID | N | Pharmacy PA | N | |
| diphenhydramine HCl | EZZ NITE SLEEP AID | LIQUID | N | Pharmacy PA | N | |
| diphenhydramine HCl | SLEEP AID | LIQUID | N | Pharmacy PA | N | |
| diphenhydramine HCl | NIGHTTIME SLEEP AID | TABLET | N | Pharmacy PA | N | |
| diphenhydramine HCl | REST SIMPLY | TABLET | N | Pharmacy PA | N | |
| diphenhydramine HCl | SLEEP TABS | TABLET | N | Pharmacy PA | N | |
| diphenhydramine HCl | SLEEP AID | TABLET | N | Pharmacy PA | N | |
| doxepin HCl | DOXEPIN HCL | TABLET | N | Pharmacy PA | N | |
| doxylamine succinate | SLEEP AID ULTRA | TABLET | N | Pharmacy PA | N | |
| doxylamine succinate | SLEEP AID | TABLET | N | Pharmacy PA | N | |
| doxylamine succinate | NIGHTTIME SLEEP AID | TABLET | N | Pharmacy PA | N | |
| estazolam | ESTAZOLAM | TABLET | N | Pharmacy PA | N | |
| eszopiclone | ESZOPICLONE | TABLET | N | Pharmacy PA | N | |
| flurazepam HCl | FLURAZEPAM HCL | CAPSULE | N | Pharmacy PA | N | |
| lemborexant | DAYVIGO | TABLET | N | Pharmacy PA | N | |
| melatonin | MELATONIN | TAB RAPDIS | 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 | |
| suvorexant | BELSOMRA | TABLET | N | Pharmacy PA | N | |
| tasimelteon | HETLIOZ | CAPSULE | N | Pharmacy PA | N | |
| tasimelteon | TASIMELTEON | CAPSULE | N | Pharmacy PA | N | |
| tasimelteon | HETLIOZ LQ | ORAL SUSP | N | Pharmacy PA | N | |
| temazepam | RESTORIL | CAPSULE | N | Pharmacy PA | N | |
| temazepam | TEMAZEPAM | CAPSULE | N | Pharmacy PA | N | |
| triazolam | HALCION | TABLET | N | Pharmacy PA | N | |
| triazolam | TRIAZOLAM | TABLET | N | Pharmacy PA | N | |
| zaleplon | ZALEPLON | CAPSULE | N | Pharmacy PA | N | |
| zolpidem tartrate | ZOLPIDEM TARTRATE | CAPSULE | N | Pharmacy PA | N | Mar 27, 2014 |
| zolpidem tartrate | AMBIEN CR | TAB MPHASE | N | Pharmacy PA | N | Mar 27, 2014 |
| zolpidem tartrate | ZOLPIDEM TARTRATE ER | TAB MPHASE | N | Pharmacy PA | N | Mar 27, 2014 |
| zolpidem tartrate | EDLUAR | TAB SUBL | N | Pharmacy PA | N | Mar 27, 2014 |
| zolpidem tartrate | ZOLPIDEM TARTRATE | TAB SUBL | N | Pharmacy PA | N | Mar 27, 2014 |
| chloral hydrate | CHLORAL HYDRATE | SYRUP | Pharmacy PA | N | ||
| melatonin/GABA/herbal no.183 | SINTRALYNE-PM | CAPSULE | Pharmacy PA | N | ||
| melatonin/magnesium citrate | SLOWMAG MG CALM-SLEEP | TABLET DR | Pharmacy PA | N | ||
| melatonin/pyridoxine HCl (B6) | MELATONIN-VITAMIN B6 | TABLET | Pharmacy PA | N |