EFFECTIVE 1/1/2021 Drug and Biologic Coverage Policy Effective Date ............................................ 1/1/2021 Next Review Date… ................................... 10/1/2021 Coverage Policy Number ............................... IP0023 Sedative Hypnotic Medications Table of Contents Related Coverage Resources Overview ...................................................................1 Multi-Source Brand Name Drugs Coverage Policy Statement ......................................1 Quantity Limitations FDA Indication Criteria ..............................................2 Other Uses with Supportive Evidence Criteria .........2 Specific Additional Criteria ........................................2 Preferred Product Requirement Criteria ...................2 Conditions Not Covered............................................4 Background ...............................................................4 References ...............................................................5 INSTRUCTIONS FOR USE The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients. Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular situation. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations. Overview This policy supports medical necessity review for the following sedative hypnotic medications: • Ambien® (zolpidem tablets) • Ambien CR® (zolpidem extended-release tablets) • Belsomra® (suvorexant) • Edluar® (zolpidem sublingual tablets) • Intermezzo® (zolpidem sublingual tablets) • Restoril® (temazepam) • Zolpimist® (zolpidem oral spray) Coverage Policy Statement Sedative hypnotic medications are medically necessary when the following are met: 1. Criteria associated with FDA Indications 2. Criteria associated with Other Uses with Supportive Evidence Page 1 of 6 Coverage Policy Number: IP0023 EFFECTIVE 1/1/2021 3. Specific Additional Criteria [when part of Cigna managed drug list or plan requirements] 4. Preferred Product Requirement Criteria [when part of Cigna managed drug list or plan requirements] When coverage is available and medically necessary, the dosage, frequency, duration of therapy, and site of care should be reasonable, clinically appropriate, and supported by evidence-based literature and adjusted based upon severity, alternative available treatments, and previous response to therapy. Approval duration is 12 months unless otherwise stated. Note: Receipt of sample product does not satisfy any criteria requirements for coverage. Documentation: When documentation is required, the prescriber must provide written documentation supporting the trials of these other agents. Documentation may include, but is not limited to, chart notes, prescription claims records, and/or prescription receipts. Refer to each criteria section below. FDA Indication Criteria 1. Chronic Insomnia. Approve for 1 year if the individual meets ONE of the following criteria (A or B): A. The individual has a cancer diagnosis; OR B. The individual meets ALL of the following criteria (i, ii, iii, iv and v): i. Individual is 18 years of age or older ii. The individual has tried at least one form of behavioral therapy for insomnia; AND Note: Examples of behavioral therapy for insomnia include relaxation training, stimulus control therapy, or sleep restriction therapy. iii. The individual is not currently taking prescription stimulants (e.g., methylphenidate, amphetamine products); AND iv. Underlying psychiatric and/or medical conditions that may cause or exacerbate insomnia have been evaluated and are currently being addressed, according to the health care professional; AND v. The individual sleep quality and quantity and/or insomnia-related daytime impairments continue to improve or remain stable, according to the health care professional Other Uses with Supportive Evidence Criteria NONE Specific Additional Criteria NONE Preferred Product Requirement Criteria Coverage varies across plans. Refer to the customer’s benefit plan document for coverage details. Where coverage requires the use of preferred products, the following criteria apply: Approve for an individual when there is documentation of ONE of the following: • The individual has had inadequate efficacy OR contraindication according to FDA label OR significant intolerance to ALL of covered alternatives according to the table below. OR • The individual is not a candidate for ALL covered alternatives according to the table below due to being subject to a warning per the prescribing information (labeling), having a disease characteristic, individual clinical factor[s], or other attributes/conditions or is unable to administer and requires this dosage formulation. Page 2 of 6 Coverage Policy Number: IP0023 EFFECTIVE 1/1/2021 Employer Group Non-Covered Products and Preferred Covered Alternatives by Drug List: Non-Covered Standard / Value / Cigna Total Legacy Product Performance Advantage Savings Ambien BOTH of the following: (brand only) • Meets Multi-Source Brand Name Drugs Policy criteria* AND Ambien CR • TWO of the following: (brand only) o doxepin (generic for Silenor) o eszopiclone (generic for Lunesta) o zaleplon (generic for Sonata) Belsomra ONE of the following: (suvorexant) • For individuals 18 to 64 years of age o THREE of the following: . Dayvigo . doxepin (generic for Silenor) . eszopiclone (generic for Lunesta) . zaleplon (generic for Sonata) . zolpidem (generic for Ambien) • For individuals 65 years of age and older o ONE of the following . Dayvigo . doxepin (generic for Silenor) . ramelteon (generic for Rozerem Edluar ONE of the following: (zolpidem • Individual cannot swallow or has difficulty swallowing solid oral dosage forms sublingual tablets) • THREE of the following: o doxepin (generic for Silenor) o eszopiclone (generic for Lunesta) o zaleplon (generic for Sonata) o zolpidem (generic for Ambien) Intermezzo ONE of the following: (brand only) • Individual cannot swallow or has difficulty swallowing solid oral dosage forms • BOTH of the following: o Meets Multi-Source Brand Name Drugs Policy criteria AND o TWO of the following: . doxepin (generic for Silenor) . eszopiclone (generic for Lunesta) . zaleplon (generic for Sonata) Restoril BOTH of the following: (brand only) • Meets Multi-Source Brand Name Drugs Policy criteria* AND • ONE of the following: o doxepin (generic for Silenor) o eszopiclone (generic for Lunesta) o zaleplon (generic for Sonata) o zolpidem (generic for Ambien) Zolpimist ONE of the following: (zolpidem oral • Individual cannot swallow or has difficulty swallowing solid oral dosage forms spray) • THREE of the following: o doxepin (generic for Silenor) o eszopiclone (generic for Lunesta) o zaleplon (generic for Sonata) o zolpidem (generic for Ambien) *Documentation that individual has tried the bioequivalent generic product AND cannot take due to a formulation difference in the inactive ingredient(s) [for example, difference in dyes, fillers, preservatives] between the brand Page 3 of 6 Coverage Policy Number: IP0023 EFFECTIVE 1/1/2021 and the bioequivalent generic product which, per the prescribing physician, would result in a significant allergy or serious adverse reaction] Conditions Not Covered 1. Any other use is considered experimental, investigational, or unproven. Criteria will be updated as new published data are available. Background Overview Eszopiclone, zaleplon, zolpidem immediate-release (IR), zolpidem extended-release (ER), zolpidem sublingual tablets, Edluar, and Zolpimist are all non-benzodiazepine sedative hypnotics used for the treatment of insomnia.1-7 These agents interact with gamma-aminobutyric acid (GABA) receptor complexes located closely to benzodiazepine receptors; the chemical structures of these agents are unrelated to the benzodiazepines. All are schedule IV controlled substances. Rozerem, another non-benzodiazepine sedative hypnotic, is a melatonin 8 9 receptor agonist. Silenor is a tricyclic compound that acts as a histamine