Clinical Policy: Zolpidem Tartrate (Edluar, Zolpimist)
Clinical coverage policy for zolpidem tartrate products (Edluar, zolpidem sublingual tablets 1.75 mg & 3.5 mg, Zolpimist) establishing initial and continued therapy medical necessity criteria, dose limits, age limits, contraindications, approval durations, formulary/redirection guidance, and references; applies to Commercial and Medicaid lines of business.
Initial policy created by splitting from CP.CPA.265 (non-benzodiazepine insomnia medications) and adding Medicaid line of business and age limit.
Increased initial approval duration for Medicaid to 6 months to align with other sleep agents.
Revised approval duration for Commercial line from length of benefit to 12 months or duration of request, whichever is less.
For brand Intermezzo requests, added requirement that member must use generic zolpidem sublingual tablet 1.75 mg or 3.5 mg (later removed when Intermezzo discontinued).
4Q annual reviews 2020-2023 noted (mostly references/template changes); 4Q2020 and 4Q2021: no significant changes; 4Q2023 removed Intermezzo as product discontinued and applied oral tablet redirection to sublingual tablet requests.
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