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

Oklahoma Health Care Authority

4345 N Lincoln Blvd

Oklahoma City, OK 73105

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