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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
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