Insomnia Medications
PHARM-13 Statement of Medical Necessity for Quantity Limits Override.
| Insomnia Medications |
Drugs | Quantity Limits |
Ambien (Zolpidem Tartrate) 5mg and 10mg Tablets | 30 Tablets per 30 Days |
Ambien CR (Zolpidem Tartrate) 6.25mg and 12.5mg Tablets | 30 Tablets per 30 Days |
Dalmane (Flurazepam HCL) 15mg and 30mg Capsules | 30 Capsules per 30 Days |
Doral (Quazepam) 15mg Tablets | 30 Tablets per 30 Days |
Edluar (Zolpidem Tartrate) 5mg and 10mg Sublingual Tablets | 30 Tablets per 30 Days |
Halcion (Triazolam) 0.125mg and 0.25mg Tablets | 30 Tablets per 30 Days |
Lunesta (Eszopicline) 1mg, 2mg and 3mg Tablets | 30 Tablets per 30 Days |
Prosom (Estazolam) 1mg and 2mg Tablets | 30 Tablets per 30 Days |
Restoril (Temazepam) 7.5mg, 15mg, 22.5mg and 30mg Capsules | 30 Capsules per 30 Days |
Rozerem (Ramelteon) 8mg Tablets | 30 Tablets per 30 Days |
Sonata (Zaleplon) 5mg and 10mg Capsules | 30 Capsules per 30 Days |
Last Modified on
Nov 17, 2020
