SELF ADMINISTRATION - ORAL
Indications for Prior Authorization:
- Treatment of insomnia, characterized by difficulties with sleep onset and/or sleep maintenance
Prior authorization criteria:
- Patient has diagnosis of insomnia and has tried and failed at least two preferred medications (e.g., estazolam, eszopiclone, ramelteon, temazepam, zaleplon, zolpidem) as confirmed by medical record documentation and/or prescription claims history
- 10 mg once per night taken within 30 minutes of going to bed, with at least 7 hours remaining before the planned time of awakening.
- Max: 20 mg once daily
- One year