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Ambien CR (zolpidem) — Blue Cross Blue Shield of Texas

insomnia

Preferred products

  • zolpidem
  • eszopiclone
  • zaleplon
  • ramelteon

Initial criteria

  • Brand Insomnia Agent(s) will be approved when ONE of the following is met:
  • 1. BOTH of the following:
  • A. ONE of the following:
  • 1. The prescriber has stated that the patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer OR
  • 2. The prescriber has submitted documentation that the patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat an associated condition related to stage four advanced metastatic cancer [chart notes are required] AND
  • B. The use of the requested agent is consistent with best practices for the treatment of stage four advanced, metastatic cancer, or an associated condition; supported by peer-reviewed, evidence-based literature; and approved by the United States Food and Drug Administration OR
  • 2. ONE of the following:
  • A. The patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed OR
  • B. The patient is currently being treated with the requested agent AND the patient is currently stable on the requested agent [chart notes are required] OR
  • C. The patient has tried and had an inadequate response to ONE prerequisite agent [chart notes are required] OR
  • D. A prerequisite agent was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event [chart notes are required] OR
  • E. The patient has an intolerance or hypersensitivity to ONE prerequisite agent [chart notes are required] OR
  • F. The patient has an FDA labeled contraindication to ALL prerequisite agents [chart notes are required] OR
  • G. A prerequisite agent is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the prescription drug; OR cause a significant barrier to adherence; OR worsen a comorbid condition; OR decrease ability to perform daily activities; OR cause an adverse reaction or harm [chart notes required] OR
  • H. A prerequisite agent is not in the best interest of the patient based on medical necessity [chart notes required] OR
  • I. The patient has tried another prescription drug in the same pharmacologic class or mechanism of action as a prerequisite agent and that prescription drug was discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required] OR
  • J. The requested agent is a non-controlled agent AND the patient requires therapy with a non-controlled agent

Approval duration

12 months