Belsomra — CareFirst (Caremark)

Preferred products

• eszopiclone
• zaleplon
• zolpidem
• temazepam

Initial criteria

• Potential factors contributing to sleep disturbances have been addressed or are currently being addressed (e.g., inappropriate sleep hygiene and sleep environment issues) as well as treatable medical/psychiatric disorders that are co-morbid with insomnia.
• The patient meets ONE of the following:
• • The patient is age ≥ 65 years.
• • The patient is age < 65 years and ONE of the following criteria is met:
• – The patient experienced an inadequate treatment response to ANY of the following: a generic non-benzodiazepine sedative-hypnotic (e.g., eszopiclone, zaleplon, zolpidem), a benzodiazepine (e.g., temazepam).
• – The patient experienced an intolerance to ANY of the following: a generic non-benzodiazepine sedative-hypnotic (e.g., eszopiclone, zaleplon, zolpidem), a benzodiazepine (e.g., temazepam).
• – The patient has a contraindication that would prohibit a trial of ALL of the following: a generic non-benzodiazepine sedative-hypnotic (e.g., eszopiclone, zaleplon, zolpidem), a benzodiazepine (e.g., temazepam).

Reauthorization criteria

• The patient has achieved or maintained a positive response to treatment from baseline.
• The patient’s need for continued therapy has been assessed.
• Potential factors contributing to sleep disturbances continue to be addressed (e.g., inappropriate sleep hygiene, sleep environment issues, treatable medical/psychiatric co-morbid disorders).

Approval duration

Initial: 6 months; Continuation: 12 months