Insomnia Medications

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

Insomnia Medications

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

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