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