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Muscle Relaxants

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

Muscle Relaxants

Drugs

Quantity Limits

Amrix (Cyclobenzaprine HCL) 15mg and 30mg SR Capsules

30 Capsules per 30 Days

Fexmid (Cyclobenzaprine HCL) 7.5mg Tablets 

90 Tablets per 30 Days

Soma (Carisoprodol) 250mg and 350mg Tablets 

120 Tablets per 30 Days

Soma Compound (Carisoprodol - Aspirin) 200mg - 325mg Tablets 

120 Tablets per 30 Days

 

Last Modified on Nov 10, 2020
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