Insomnia Medications

PHARM-13 Statement of Medical Necessity for Quantity Limits Override.

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

Oklahoma Health Care Authority

4345 N Lincoln Blvd

Oklahoma City, OK 73105

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