Ambien CR (zolpidem) — Blue Cross Blue Shield of New Mexico

insomnia (quantity limit criteria)

Initial criteria

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 BOTH of the following:
A. ONE of the following:
1. BOTH of the following:
A. The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND
B. There is support for therapy with a higher dose for the requested indication OR
2. BOTH of the following:
A. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
B. 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:
A. The requested quantity (dose) exceeds the maximum FDA labeled dose for the requested indication AND
B. There is support for therapy with a higher dose for the requested indication AND
B. ONE of the following:
1. The patient is using one insomnia agent OR
2. BOTH of the following:
A. The patient is using TWO insomnia agents AND
B. The previous insomnia agent will be discontinued and replaced by the requested agent

12 months