Benzodiazepine
PHARM-13 Statement of Medical Necessity for Quantity Limits Override.
| Benzodiazepine | ||
|---|---|---|
Drugs | Quantity Limits | |
Ativan (Lorazepam) | 90 per 30 days | |
Librium (Chlordiazepoxide) | 90 per 30 days | |
Serax (Oxazepam) | 90 per 30 days | |
Tranxene (Clorazepate Dipotassium) | 90 per 30 days | |
Valium (Diazepam) | 90 per 30 days | |
Xanax (Alprazolam) | 90 per 30 days | |
Xanax XR (Alprazolam extended release) | 30 per 30 days, except the 2mg, which is #60 per 30 | |
Last Modified on
Nov 12, 2020
