SEDATIVE-HYPNOTIC STEP THERAPY
The Sedative-hypnotic step therapy allows the coverage of formulary non-benzodiazipine hypnotics after the use of a benzodiazipine hypnotic within 130 days (4 months), while not interrupting existing therapy. This step therapy is not applied to persons who are 60 years of age or older related to the risks associated with use of benzodiazipines for this age group.
Sedative-hypnotic Step Therapy : Non-benzodiazipine hypnotics,Ambien and Sonata, will be covered if dispensed within 130 days of one of the following products—flurazepam, hydroxyzine hcl, temazepam, and triazolam. If the member has had >1 prescription of Ambien and Sonata within the past 130n days, it will also process with no prior authorization required (PAR). If the member has already tried the drug to be dispensed, they are allowed to continue to get it without a prior authorization.
If the step therapy rule is not met at the point of service, (when the prescription is processed at the pharmacy), the pharmacy will be directed, via electronic messaging from the PBM, to contact the practitioner for a benzodiazepine hypnotic. Should the practitioner choose to use the second-line hypnotic without meeting the step criteria, and the participant wants the prescription given special consideration for payment from their prescription drug benefit, the practitioner must contact Health Care Services at MAHP and provide additional medical/clinical information. If the medical/clinical information meets criteria for a medical exception to this step therapy, a prior authorization may be granted.
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FIRST-LINE DRUGS |
SECOND-LINE DRUGS |
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MEDICATIONS |
Benzodiazipine hypnotics—flurazepam (DALMANE), hydroxyzine (VISTARIL), hydroxyzine HCL (ATARAX), temazepam (RESTORIL), triazolam (HALCION) |
AMBIEN – Zolpidem Tartratte SONATA - Zaleplon |
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CRITERIA FOR USE |
Driven by formulary status of drug, formulary is closed and MAC policies **Processing of brand name first-line drug will cause ancillary charges to participant if a multi-source drug. |
Participant has one RX in claims history from the first-line drug category within 130 days prior to the prescription date of a second-line drug OR Participant has a prescription written by a psychiatric practitioner with other “psych” medications. OR Age 60 yrs or older |
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