Updated versions may be found at www.pbm.va.gov or http://vaww.pbm.va.gov
Criteria for Nonformulary Use of Eszopiclone (Lunesta)
VHA Pharmacy Benefits Management Strategic Healthcare Group and the Medical Advisory Panel
The following recommendations are based on current medical evidence and expert opinion from clinicians. The content of the document is dynamic
and will be revised as new clinical data becomes available. The purpose of this document is to assist practitioners in clinical decision-making, to
standardize and improve the quality of patient care, and to promote cost-effective drug prescribing. The clinician should utilize this guidance and
interpret it in the clinical context of the individual patient situation.
Patient with symptoms of insomnia associated with one or more of the following
1. A psychiatric and/or medical illness without any, or an inadequate trial, of other
formulary alternatives or nonpharmacological interventions deemed appropriate
to use (e.g., sedating antidepressants, benzodiazepines).
3. Active alcohol/illicit drug use/abuse/dependence
4. Concurrent use with any other sedative hypnotics or other medications including
over-the counter analgesics that contain caffeine or herbal supplements (e.g.,
melatonin, St. John’s Wort) for the treatment of symptoms related to insomnia.
5. No attempts or consideration has been made and documented to discontinue or
adjust any medications/substances known to affect sleep
If any of the boxes are checked, patient is not a
candidate to receive eszopiclone.
If none of the boxes is checked, proceed to the
Inclusion Criteria for Therapy section below.
*Part of the evaluation of insomnia should
include assessment of other drugs or conditions
(e.g. chemical dependence, sleep apnea) that may
be interfering with sleep.
Inclusion Criteria for Short-Term Therapy for Insomnia
1. Patient with acute (short-term) insomnia defined as periods of sleep difficulty
lasting less than one