On March 22, a DoD panel proposed moving several pain, glaucoma, and antidepressant medications to the third tier ($22 copay vs $3 or $9 for drugs on first and second tiers), along with some newer sedatives.

Ultram ER (extended release) will be moved to the third tier with a 90-day implementation time. There are 38 other medications in this class that remain available at the lower copays, including the immediate-release form of Ultram.

Glaucoma drugs Travatan, Istalol, Betimol, and Azopt to the third tier, while 18 medications in this class will still be available at the lower copay.

Among anti-depressants, the Emsam patch will move to the third tier, leaving Marplan, Nardil and Parnate available at lower copays.

Some newer sedatives -- Rozerem, Sonata, and Ambien CR (controlled release) - also will move to the third tier.

Ambien and Lunesta will remain on the lower-copay list, along with eight other older drugs.

However, a "prior-authorization" requirement is being proposed for first-time use of all drugs in this class other than Ambien, which is the most commonly prescribed and cost-effective drug in this class.

The prior-authorization requirement would not apply to patients who previously had another first- or second-tier sleep agent prescribed in the last six months.

NOTE: the panel indicated that Ambien is scheduled to be available in generic form in April. When that happens, use of that generic will be made mandatory.

Other drugs in the class will be available only if the doctor demonstrates that there is a medical necessity to prescribe one of the other drugs in the class for the particular patient (e.g., to avoid adverse side effects).