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• lunesta Costa Mesa, CA 92626 Lunesta® (eszopiclone) Prior Authorization Request Form DO NOT COPY FOR FUTURE USE .
FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED Member Information (required) lunesta Provider Information (required) Office Street Address: Medication Information (required) Medication Name:  Check if requesting brand  Check if request is for continuation of therapy Is the physician supplying the medication?  Yes  No Directions for Use: Clinical Information (required) Select the diagnosis below:  Other diagnosis: ______________________________ ICD-10 Code(s): _____________________________________ The approval criteria is based on the guidance provided by the Centers for Medicare & Medicaid Services (CMS), the Pharmacy Quality Alliance, the American Geriatric Society and the National Committee for Quality Assurance (NCQA) .
"Use of High Risk Medications in the lunesta Elderly" is measure 238 of the Centers for Medicare & Medicaid Services Physician Quality Reporting System .
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