Under some plans, including plans that use an open or closed formulary zolpidem, Ambien, Ambien CR, Lunesta, Rozerem and Sonata are subject to precertification.  If precertification requirements apply Aetna considers, zolpidem, Ambien, Ambien CR, Lunesta, Rozerem or Sonata to be medically necessary for those members who meet the following precertification criteria:

According to the manufacturer, the sedative/hypnotics zolpidem, Ambien, Ambien CR, Lunesta, Rozerem and Sonata can be dosed up to a maximum daily dose at the interval(s) as indicated in the table below. A quantity of each drug will be considered medically necessary as indicated in the table below;

For coverage of additional quantities, a member's treating physician must request prior authorization through the Pharmacy Management Precertification Unit. Additional quantities of drug class/brand names will be considered medically necessary for those members who meet ANY of the following criteria:

• Member requires a dose including half tablets (zolpidem/Ambien only)OR
• Member's dose is being titrated by physician (3-month limit) OR 
• Member has had failure to drug administered as a single dose at night (zolpidem/Ambien 10mg) and requires twice dosing at night (zolpidem/Ambien 5mg) OR
• Member's physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a higher dose.

Under some plans, including plans that use an open or closed formulary, Ambien, Ambien CR, Lunesta, Rozerem, and Sonata are subject to step-therapy.  Aetna considers Ambien, Ambien CR, Lunesta, Rozerem, and Sonata to be medically necessary for those members who meet the following step-therapy criteria:

A documented trial of  7 days (one week) of the preferred generic alternative zolpidem.

If it is medically necessary for a member to be treated initially with a medication subject to step-therapy, the member's treating physician may contact the Aetna Pharmacy Management Precertification Unit to request coverage as a medical exception. (See criteria under section III below.)

Ambien,  Lunesta, Rozerem and Sonata are currently listed on the Aetna Formulary Exclusions and Step-Therapy lists.* Therefore, these drugs are excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary or that require step-therapy criteria, unless a medical exception is granted. Aetna considers Ambien,  Lunesta, Rozerem and Sonata to be medically necessary for those members who meet the following criteria

Ambien CR is listed on the Aetna Step-Therapy List.* Therefore, it is excluded from coverage for members enrolled in prescription drug benefit plans that require step-therapy criteria, unless a medical exception is granted.  Aetna considers Ambien CR  to be medically necessary for those members who meet the following criteria:

For Ambien, Ambien CR, Lunesta, Rozerem and Sonata

A.  A documented: 

•  Intolerance to  preferred generic alternative zolpidem for sleep OR
•  Contraindication to  preferred generic alternative zolpidem for sleep OR
•  Allergy to preferred generic alternative zolpidem for sleep OR
•  Failure of an adequate trial of 7 days (one week) of preferred generic alternative zolpidem for sleep OR
•  History of substance abuse (for Rozerem only )
  

Doral and  Strazepam pak are currently listed on the Aetna Formulary Exclusions List.* Therefore, they are excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary, unless a medical exception is granted.  Aetna considers Doral and Strazepam pak to be medically necessary for those members who meet ANY of the following criteria:

For Doral

A.  A documented: 

• Intolerance to two preferred alternatives for sleep OR
• Contraindication to two preferred alternatives for sleep OR
• Allergy to two preferred alternatives for sleep OR
• Failure of an adequate trial of 7 days (one week) each of two preferred alternatives for sleep
  

For Strazepam pak

• Intolerance to two preferred alternatives for sleep (one of which should be temazepam) OR
• Contraindication to two preferred alternatives for sleep (one of which should be temazepam)  OR
• Allergy to two preferred alternatives for sleep (one of which should be temazepam)  OR
• Failure of an adequate trial of 7 days (one week) each of 2 preferred alternatives for sleep (one of which should be temazepam)