What alternative sleep aids can be used for insomnia if suvorexant (Belsomra) or doxepin 3-6 mg are not covered by insurance?

Alternative Sleep Medications When Suvorexant and Low-Dose Doxepin Are Not Covered

For sleep maintenance insomnia, use eszopiclone 2-3 mg or zolpidem 10 mg as your first alternative; for sleep onset insomnia specifically, use ramelteon 8 mg or zaleplon 10 mg. 1, 2

Algorithm for Selecting Alternative Agents

For Sleep Maintenance Insomnia (Difficulty Staying Asleep)

First-line alternatives:

• Eszopiclone 2-3 mg is the strongest alternative, effective for both sleep onset and maintenance with demonstrated superiority over placebo on sleep duration and efficiency 1, 2
• Zolpidem 10 mg is equally effective for maintenance insomnia and works for both onset and maintenance problems 1, 2

Second-line alternative:

• Temazepam 15 mg (traditional benzodiazepine) is effective for both onset and maintenance but carries higher risks of cognitive impairment and dependence compared to Z-drugs 1, 2

For Sleep Onset Insomnia (Difficulty Falling Asleep)

First-line alternatives:

• Ramelteon 8 mg is the safest option with minimal cognitive risk, working as a melatonin receptor agonist without affecting GABA receptors 1, 2, 3
• Zaleplon 10 mg has a shorter duration of action, making it ideal for onset problems without next-day effects 1, 2

Second-line alternative:

• Triazolam 0.25 mg is effective for sleep onset but carries benzodiazepine-related risks 1

For Mixed Insomnia (Both Onset and Maintenance)

Prioritize eszopiclone 2-3 mg or zolpidem 10 mg as these address both components effectively 1, 2

Critical Prescribing Principles

Start with the lowest effective dose and use for the shortest necessary duration, with follow-up every few weeks initially to assess effectiveness and side effects 2

Consider intermittent dosing (three nights per week) or as-needed use to reduce tolerance and dependence risk 2

All Z-drugs (zolpidem, eszopiclone, zaleplon) act on GABA receptors and carry cognitive side effect risks including amnesia and potential contribution to dementia with long-term use 2

Medications to Explicitly Avoid

Do not use the following agents as they are specifically not recommended by the American Academy of Sleep Medicine:

• Trazodone 50 mg - explicitly recommended against despite common off-label use 1, 4
• Diphenhydramine (over-the-counter antihistamines) - anticholinergic effects, lack of efficacy and safety data 1, 2
• Melatonin 2 mg - insufficient evidence for efficacy 1, 2
• Valerian and herbal supplements - lack efficacy and safety data 1, 2
• Tiagabine 4 mg - insufficient benefit 1

Special Considerations for Cost-Conscious Prescribing

Generic formulations of eszopiclone, zolpidem, zaleplon, temazepam, and ramelteon are typically well-covered by insurance and significantly less expensive than branded suvorexant 5, 6

Ramelteon offers the best safety profile if cost is similar to Z-drugs, particularly for elderly patients or those with addiction concerns 2, 7, 3

Patient Education Requirements

Educate patients about:

• Realistic expectations for improvement 2
• Potential for rebound insomnia upon discontinuation 2
• Risk of dosage escalation with chronic use 2
• Importance of combining medication with sleep hygiene practices 2
• Next-day cognitive effects, particularly with driving 2

When to Reassess

If inadequate response after 2-3 weeks, switch to an alternative agent from the recommended list rather than increasing dose 4

Consider cognitive behavioral therapy for insomnia (CBT-I) as an adjunctive treatment to facilitate eventual medication discontinuation 2