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

Oklahoma Health Care Authority

4345 N Lincoln Blvd

Oklahoma City, OK 73105

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