Sedatives
PDL Reference Documents
- Circadian Rhythm Sleep Disorders - Apr 06, 2023
- Sedative PA Update - Dec 01, 2022
- Sedatives Update with New Drug Eval - Aug 04, 2022
- Sedatives - Dec 03, 2020
- Sedatives - Jul 26, 2018
- Sedatives Class Update - Mar 23, 2017
- Insomnia Drug Class Update - Nov 20, 2014
- Insomnia Scan Summary - Nov 21, 2013
- Class Scan: Sedative Hypnotics - Mar 29, 2012
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 |
---|---|---|---|---|---|
melatonin | MELATONIN | TABLET | Y | PA Document | |
ramelteon | RAMELTEON | TABLET | Y | PA Document | |
ramelteon | ROZEREM | TABLET | Y | PA Document | |
zolpidem tartrate | ZOLPIDEM TARTRATE | TABLET | Y | PA Document | |
zolpidem tartrate | AMBIEN | TABLET | Y | PA Document | |
daridorexant HCl | QUVIVIQ | TABLET | N | PA Document | |
diphenhydramine HCl | NIGHTTIME SLEEP AID | CAPSULE | N | PA Document | |
diphenhydramine HCl | SLEEP TIME | CAPSULE | N | PA Document | |
diphenhydramine HCl | SLEEP AID | CAPSULE | N | PA Document | |
diphenhydramine HCl | SLEEP-AID | CAPSULE | N | PA Document | |
diphenhydramine HCl | SLEEP TIME | LIQUID | N | PA Document | |
diphenhydramine HCl | SLEEP AID | LIQUID | N | PA Document | |
diphenhydramine HCl | SLEEP TABS | TABLET | N | PA Document | |
diphenhydramine HCl | SLEEP AID | TABLET | N | PA Document | |
diphenhydramine HCl | NIGHTTIME SLEEP AID | TABLET | N | PA Document | |
doxepin HCl | DOXEPIN HCL | TABLET | N | PA Document | |
doxylamine succinate | SLEEP AID | TABLET | N | PA Document | |
doxylamine succinate | NIGHTTIME SLEEP AID | TABLET | N | PA Document | |
estazolam | ESTAZOLAM | TABLET | N | PA Document | |
eszopiclone | LUNESTA | TABLET | N | PA Document | |
eszopiclone | ESZOPICLONE | TABLET | N | PA Document | |
flurazepam HCl | FLURAZEPAM HCL | CAPSULE | N | PA Document | |
lemborexant | DAYVIGO | TABLET | N | PA Document | |
melatonin | MELATONIN | TAB RAPDIS | N | PA Document | |
midazolam HCl | MIDAZOLAM HCL | SYRUP | N | PA Document | |
quazepam | QUAZEPAM | TABLET | N | PA Document | |
quazepam | DORAL | TABLET | N | PA Document | |
suvorexant | BELSOMRA | TABLET | N | PA Document | |
tasimelteon | TASIMELTEON | CAPSULE | N | PA Document | |
tasimelteon | HETLIOZ | CAPSULE | N | PA Document | |
tasimelteon | HETLIOZ LQ | ORAL SUSP | N | PA Document | |
temazepam | TEMAZEPAM | CAPSULE | N | PA Document | |
temazepam | RESTORIL | CAPSULE | N | PA Document | |
triazolam | TRIAZOLAM | TABLET | N | PA Document | |
triazolam | HALCION | TABLET | N | PA Document | |
zaleplon | ZALEPLON | CAPSULE | N | PA Document | |
zolpidem tartrate | ZOLPIDEM TARTRATE | CAPSULE | N | PA Document | |
zolpidem tartrate | ZOLPIDEM TARTRATE ER | TAB MPHASE | N | PA Document | |
zolpidem tartrate | AMBIEN CR | TAB MPHASE | N | PA Document | |
zolpidem tartrate | ZOLPIDEM TARTRATE | TAB SUBL | N | PA Document | |
zolpidem tartrate | EDLUAR | TAB SUBL | N | PA Document | |
chloral hydrate | CHLORAL HYDRATE | SYRUP | PA Document | ||
melatonin/magnesium citrate | SLOWMAG MG CALM-SLEEP | TABLET DR | PA Document | ||
melatonin/pyridoxine HCl (B6) | MELATONIN-VITAMIN B6 | TABLET | PA Document |