Benzodiazepines

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
00054306844 ALPRAZOLAM INTENSOL alprazolam ORAL CONC 1 mg/mL Y Y Quantity Limit
00228308306 ALPRAZOLAM ER alprazolam TAB ER 24H 0.5 mg Y Y Quantity Limit
65862045460 ALPRAZOLAM ER alprazolam TAB ER 24H 0.5 mg Y Y Quantity Limit
59762005701 ALPRAZOLAM XR alprazolam TAB ER 24H 0.5 mg Y Y Quantity Limit
58151050391 XANAX XR alprazolam TAB ER 24H 0.5 mg Y Y Quantity Limit
00228308406 ALPRAZOLAM ER alprazolam TAB ER 24H 1 mg Y Y Quantity Limit
65862045560 ALPRAZOLAM ER alprazolam TAB ER 24H 1 mg Y Y Quantity Limit
59762005901 ALPRAZOLAM XR alprazolam TAB ER 24H 1 mg Y Y Quantity Limit
58151050491 XANAX XR alprazolam TAB ER 24H 1 mg Y Y Quantity Limit
00228308706 ALPRAZOLAM ER alprazolam TAB ER 24H 2 mg Y Y Quantity Limit
65862045660 ALPRAZOLAM ER alprazolam TAB ER 24H 2 mg Y Y Quantity Limit
59762006601 ALPRAZOLAM XR alprazolam TAB ER 24H 2 mg Y Y Quantity Limit
58151050591 XANAX XR alprazolam TAB ER 24H 2 mg Y Y Quantity Limit
00228308606 ALPRAZOLAM ER alprazolam TAB ER 24H 3 mg Y Y Quantity Limit
65862045760 ALPRAZOLAM ER alprazolam TAB ER 24H 3 mg Y Y Quantity Limit
59762006801 ALPRAZOLAM XR alprazolam TAB ER 24H 3 mg Y Y Quantity Limit
58151050691 XANAX XR alprazolam TAB ER 24H 3 mg Y Y Quantity Limit
00228401911 ALPRAZOLAM ODT alprazolam TAB RAPDIS 0.25 mg Y Y Quantity Limit
49884011052 ALPRAZOLAM ODT alprazolam TAB RAPDIS 0.25 mg Y Y Quantity Limit
49884011074 ALPRAZOLAM ODT alprazolam TAB RAPDIS 0.25 mg Y Y Quantity Limit
00228402211 ALPRAZOLAM ODT alprazolam TAB RAPDIS 0.5 mg Y Y Quantity Limit
49884011152 ALPRAZOLAM ODT alprazolam TAB RAPDIS 0.5 mg Y Y Quantity Limit
49884011174 ALPRAZOLAM ODT alprazolam TAB RAPDIS 0.5 mg Y Y Quantity Limit
00228402411 ALPRAZOLAM ODT alprazolam TAB RAPDIS 1 mg Y Y Quantity Limit
49884021352 ALPRAZOLAM ODT alprazolam TAB RAPDIS 1 mg Y Y Quantity Limit
49884021374 ALPRAZOLAM ODT alprazolam TAB RAPDIS 1 mg Y Y Quantity Limit
00228402511 ALPRAZOLAM ODT alprazolam TAB RAPDIS 2 mg Y Y Quantity Limit
49884021452 ALPRAZOLAM ODT alprazolam TAB RAPDIS 2 mg Y Y Quantity Limit
49884021474 ALPRAZOLAM ODT alprazolam TAB RAPDIS 2 mg Y Y Quantity Limit
00228202710 ALPRAZOLAM alprazolam TABLET 0.25 mg Y Y Quantity Limit
00228202750 ALPRAZOLAM alprazolam TABLET 0.25 mg Y Y Quantity Limit
00228202796 ALPRAZOLAM alprazolam TABLET 0.25 mg Y Y Quantity Limit
00781106101 ALPRAZOLAM alprazolam TABLET 0.25 mg Y Y Quantity Limit
00781106105 ALPRAZOLAM alprazolam TABLET 0.25 mg Y Y Quantity Limit
00781106110 ALPRAZOLAM alprazolam TABLET 0.25 mg Y Y Quantity Limit
50268003311 ALPRAZOLAM alprazolam TABLET 0.25 mg Y Y Quantity Limit
50268003315 ALPRAZOLAM alprazolam TABLET 0.25 mg Y Y Quantity Limit
51079078817 ALPRAZOLAM alprazolam TABLET 0.25 mg Y Y Quantity Limit
59762371901 ALPRAZOLAM alprazolam TABLET 0.25 mg Y Y Quantity Limit
59762371903 ALPRAZOLAM alprazolam TABLET 0.25 mg Y Y Quantity Limit
59762371904 ALPRAZOLAM alprazolam TABLET 0.25 mg Y Y Quantity Limit
60687037701 ALPRAZOLAM alprazolam TABLET 0.25 mg Y Y Quantity Limit
60687037711 ALPRAZOLAM alprazolam TABLET 0.25 mg Y Y Quantity Limit
62584060901 ALPRAZOLAM alprazolam TABLET 0.25 mg Y Y Quantity Limit
62584060933 ALPRAZOLAM alprazolam TABLET 0.25 mg Y Y Quantity Limit
65862067601 ALPRAZOLAM alprazolam TABLET 0.25 mg Y Y Quantity Limit
65862067605 ALPRAZOLAM alprazolam TABLET 0.25 mg Y Y Quantity Limit
65862067699 ALPRAZOLAM alprazolam TABLET 0.25 mg Y Y Quantity Limit
00009002901 XANAX alprazolam TABLET 0.25 mg Y Y Quantity Limit
00009002902 XANAX alprazolam TABLET 0.25 mg Y Y Quantity Limit
00228202910 ALPRAZOLAM alprazolam TABLET 0.5 mg Y Y Quantity Limit
00228202950 ALPRAZOLAM alprazolam TABLET 0.5 mg Y Y Quantity Limit
00228202996 ALPRAZOLAM alprazolam TABLET 0.5 mg Y Y Quantity Limit
00781107701 ALPRAZOLAM alprazolam TABLET 0.5 mg Y Y Quantity Limit
00781107705 ALPRAZOLAM alprazolam TABLET 0.5 mg Y Y Quantity Limit
00781107710 ALPRAZOLAM alprazolam TABLET 0.5 mg Y Y Quantity Limit
50268003411 ALPRAZOLAM alprazolam TABLET 0.5 mg Y Y Quantity Limit
50268003415 ALPRAZOLAM alprazolam TABLET 0.5 mg Y Y Quantity Limit
59762372001 ALPRAZOLAM alprazolam TABLET 0.5 mg Y Y Quantity Limit
59762372003 ALPRAZOLAM alprazolam TABLET 0.5 mg Y Y Quantity Limit
59762372004 ALPRAZOLAM alprazolam TABLET 0.5 mg Y Y Quantity Limit
60687038801 ALPRAZOLAM alprazolam TABLET 0.5 mg Y Y Quantity Limit
60687038811 ALPRAZOLAM alprazolam TABLET 0.5 mg Y Y Quantity Limit
62584061001 ALPRAZOLAM alprazolam TABLET 0.5 mg Y Y Quantity Limit
65862067701 ALPRAZOLAM alprazolam TABLET 0.5 mg Y Y Quantity Limit
65862067705 ALPRAZOLAM alprazolam TABLET 0.5 mg Y Y Quantity Limit
65862067799 ALPRAZOLAM alprazolam TABLET 0.5 mg Y Y Quantity Limit
00009005501 XANAX alprazolam TABLET 0.5 mg Y Y Quantity Limit
00009005503 XANAX alprazolam TABLET 0.5 mg Y Y Quantity Limit
58151045301 XANAX alprazolam TABLET 0.5 mg Y Y Quantity Limit
58151045305 XANAX alprazolam TABLET 0.5 mg Y Y Quantity Limit
00228203110 ALPRAZOLAM alprazolam TABLET 1 mg Y Y Quantity Limit
00228203150 ALPRAZOLAM alprazolam TABLET 1 mg Y Y Quantity Limit
00228203196 ALPRAZOLAM alprazolam TABLET 1 mg Y Y Quantity Limit
00781107901 ALPRAZOLAM alprazolam TABLET 1 mg Y Y Quantity Limit
00781107905 ALPRAZOLAM alprazolam TABLET 1 mg Y Y Quantity Limit
00781107910 ALPRAZOLAM alprazolam TABLET 1 mg Y Y Quantity Limit
50268003511 ALPRAZOLAM alprazolam TABLET 1 mg Y Y Quantity Limit
50268003515 ALPRAZOLAM alprazolam TABLET 1 mg Y Y Quantity Limit
59762372101 ALPRAZOLAM alprazolam TABLET 1 mg Y Y Quantity Limit
59762372103 ALPRAZOLAM alprazolam TABLET 1 mg Y Y Quantity Limit
59762372104 ALPRAZOLAM alprazolam TABLET 1 mg Y Y Quantity Limit
62584061101 ALPRAZOLAM alprazolam TABLET 1 mg Y Y Quantity Limit
62584061133 ALPRAZOLAM alprazolam TABLET 1 mg Y Y Quantity Limit
65862067801 ALPRAZOLAM alprazolam TABLET 1 mg Y Y Quantity Limit
65862067805 ALPRAZOLAM alprazolam TABLET 1 mg Y Y Quantity Limit
65862067899 ALPRAZOLAM alprazolam TABLET 1 mg Y Y Quantity Limit
00009009001 XANAX alprazolam TABLET 1 mg Y Y Quantity Limit
00009009004 XANAX alprazolam TABLET 1 mg Y Y Quantity Limit
58151045401 XANAX alprazolam TABLET 1 mg Y Y Quantity Limit
00228203910 ALPRAZOLAM alprazolam TABLET 2 mg Y Y Quantity Limit
00781108901 ALPRAZOLAM alprazolam TABLET 2 mg Y Y Quantity Limit
00781108905 ALPRAZOLAM alprazolam TABLET 2 mg Y Y Quantity Limit
49884040001 ALPRAZOLAM alprazolam TABLET 2 mg Y Y Quantity Limit
49884040005 ALPRAZOLAM alprazolam TABLET 2 mg Y Y Quantity Limit
59762372201 ALPRAZOLAM alprazolam TABLET 2 mg Y Y Quantity Limit
59762372203 ALPRAZOLAM alprazolam TABLET 2 mg Y Y Quantity Limit
65862067901 ALPRAZOLAM alprazolam TABLET 2 mg Y Y Quantity Limit
65862067905 ALPRAZOLAM alprazolam TABLET 2 mg Y Y Quantity Limit
00009009401 XANAX alprazolam TABLET 2 mg Y Y Quantity Limit
00378021101 CHLORDIAZEPOXIDE-AMITRIPTYLINE amitriptyline/chlordiazepoxide TABLET 12.5 mg-5 mg Y Y Quantity Limit
00378021105 CHLORDIAZEPOXIDE-AMITRIPTYLINE amitriptyline/chlordiazepoxide TABLET 12.5 mg-5 mg Y Y Quantity Limit
00378027701 CHLORDIAZEPOXIDE-AMITRIPTYLINE amitriptyline/chlordiazepoxide TABLET 25 mg-10 mg Y Y Quantity Limit
00378027705 CHLORDIAZEPOXIDE-AMITRIPTYLINE amitriptyline/chlordiazepoxide TABLET 25 mg-10 mg Y Y Quantity Limit
00555003302 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 10 mg Y Y Quantity Limit
00555003305 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 10 mg Y Y Quantity Limit
42806056201 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 10 mg Y Y Quantity Limit
42806056501 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 10 mg Y Y Quantity Limit
43547025210 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 10 mg Y Y Quantity Limit
51079037501 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 10 mg Y Y Quantity Limit
51079037520 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 10 mg Y Y Quantity Limit
62135022160 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 10 mg Y Y Quantity Limit
62584064701 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 10 mg Y Y Quantity Limit
00555015902 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 25 mg Y Y Quantity Limit
00555015904 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 25 mg Y Y Quantity Limit
42806056301 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 25 mg Y Y Quantity Limit
42806056601 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 25 mg Y Y Quantity Limit
43547025310 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 25 mg Y Y Quantity Limit
51079014101 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 25 mg Y Y Quantity Limit
51079014120 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 25 mg Y Y Quantity Limit
60687080701 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 25 mg Y Y Quantity Limit
60687080711 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 25 mg Y Y Quantity Limit
62135022260 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 25 mg Y Y Quantity Limit
62584064801 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 25 mg Y Y Quantity Limit
00555015802 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 5 mg Y Y Quantity Limit
00555015804 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 5 mg Y Y Quantity Limit
42806056401 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 5 mg Y Y Quantity Limit
43547025110 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 5 mg Y Y Quantity Limit
51079037401 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 5 mg Y Y Quantity Limit
51079037420 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 5 mg Y Y Quantity Limit
62135022060 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 5 mg Y Y Quantity Limit
62584064601 CHLORDIAZEPOXIDE HCL chlordiazepoxide HCl CAPSULE 5 mg Y Y Quantity Limit
11534019701 CHLORDIAZEPOXIDE-CLIDINIUM chlordiazepoxide/clidinium Br CAPSULE 5 mg-2.5 mg Y N Quantity Limit
23155080801 CHLORDIAZEPOXIDE-CLIDINIUM chlordiazepoxide/clidinium Br CAPSULE 5 mg-2.5 mg Y N Quantity Limit
42571038101 CHLORDIAZEPOXIDE-CLIDINIUM chlordiazepoxide/clidinium Br CAPSULE 5 mg-2.5 mg Y N Quantity Limit
59651052401 CHLORDIAZEPOXIDE-CLIDINIUM chlordiazepoxide/clidinium Br CAPSULE 5 mg-2.5 mg Y N Quantity Limit
60219167701 CHLORDIAZEPOXIDE-CLIDINIUM chlordiazepoxide/clidinium Br CAPSULE 5 mg-2.5 mg Y N Quantity Limit
60687063911 CHLORDIAZEPOXIDE-CLIDINIUM chlordiazepoxide/clidinium Br CAPSULE 5 mg-2.5 mg Y N Quantity Limit
60687063994 CHLORDIAZEPOXIDE-CLIDINIUM chlordiazepoxide/clidinium Br CAPSULE 5 mg-2.5 mg Y N Quantity Limit
62135069612 CHLORDIAZEPOXIDE-CLIDINIUM chlordiazepoxide/clidinium Br CAPSULE 5 mg-2.5 mg Y N Quantity Limit
62332074431 CHLORDIAZEPOXIDE-CLIDINIUM chlordiazepoxide/clidinium Br CAPSULE 5 mg-2.5 mg Y N Quantity Limit
67877073101 CHLORDIAZEPOXIDE-CLIDINIUM chlordiazepoxide/clidinium Br CAPSULE 5 mg-2.5 mg Y N Quantity Limit
70700018501 CHLORDIAZEPOXIDE-CLIDINIUM chlordiazepoxide/clidinium Br CAPSULE 5 mg-2.5 mg Y N Quantity Limit
00093929019 CLONAZEPAM clonazepam TAB RAPDIS 0.125 mg N Y N Quantity Limit
00093929067 CLONAZEPAM clonazepam TAB RAPDIS 0.125 mg N Y N Quantity Limit
49884030602 CLONAZEPAM clonazepam TAB RAPDIS 0.125 mg N Y N Quantity Limit
49884030652 CLONAZEPAM clonazepam TAB RAPDIS 0.125 mg N Y N Quantity Limit
57664078386 CLONAZEPAM clonazepam TAB RAPDIS 0.125 mg N Y N Quantity Limit
62332036406 CLONAZEPAM clonazepam TAB RAPDIS 0.125 mg N Y N Quantity Limit
00093929119 CLONAZEPAM clonazepam TAB RAPDIS 0.25 mg N Y N Quantity Limit
00093929167 CLONAZEPAM clonazepam TAB RAPDIS 0.25 mg N Y N Quantity Limit
49884030702 CLONAZEPAM clonazepam TAB RAPDIS 0.25 mg N Y N Quantity Limit
49884030752 CLONAZEPAM clonazepam TAB RAPDIS 0.25 mg N Y N Quantity Limit
57664078486 CLONAZEPAM clonazepam TAB RAPDIS 0.25 mg N Y N Quantity Limit
62332036506 CLONAZEPAM clonazepam TAB RAPDIS 0.25 mg N Y N Quantity Limit
00093929219 CLONAZEPAM clonazepam TAB RAPDIS 0.5 mg N Y N Quantity Limit
00093929267 CLONAZEPAM clonazepam TAB RAPDIS 0.5 mg N Y N Quantity Limit
49884030802 CLONAZEPAM clonazepam TAB RAPDIS 0.5 mg N Y N Quantity Limit
49884030852 CLONAZEPAM clonazepam TAB RAPDIS 0.5 mg N Y N Quantity Limit
57664078586 CLONAZEPAM clonazepam TAB RAPDIS 0.5 mg N Y N Quantity Limit
62332036606 CLONAZEPAM clonazepam TAB RAPDIS 0.5 mg N Y N Quantity Limit
00093929319 CLONAZEPAM clonazepam TAB RAPDIS 1 mg N Y N Quantity Limit
00093929367 CLONAZEPAM clonazepam TAB RAPDIS 1 mg N Y N Quantity Limit
49884030902 CLONAZEPAM clonazepam TAB RAPDIS 1 mg N Y N Quantity Limit
49884030952 CLONAZEPAM clonazepam TAB RAPDIS 1 mg N Y N Quantity Limit
57664078686 CLONAZEPAM clonazepam TAB RAPDIS 1 mg N Y N Quantity Limit
62332036706 CLONAZEPAM clonazepam TAB RAPDIS 1 mg N Y N Quantity Limit
00093929419 CLONAZEPAM clonazepam TAB RAPDIS 2 mg N Y N Quantity Limit
00093929467 CLONAZEPAM clonazepam TAB RAPDIS 2 mg N Y N Quantity Limit
49884031002 CLONAZEPAM clonazepam TAB RAPDIS 2 mg N Y N Quantity Limit
49884031052 CLONAZEPAM clonazepam TAB RAPDIS 2 mg N Y N Quantity Limit
57664078786 CLONAZEPAM clonazepam TAB RAPDIS 2 mg N Y N Quantity Limit
62332036806 CLONAZEPAM clonazepam TAB RAPDIS 2 mg N Y N Quantity Limit
00093083201 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
00093083205 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
00904722761 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
16729013600 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
16729013616 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
43547040610 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
43547040611 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
43547040650 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
49884049505 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
50268017311 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
50268017315 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
57664027308 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
57664027313 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
57664027318 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
59651072201 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
59651072299 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
60687086101 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
60687086111 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
62135076990 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
72603030701 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
72603030702 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
72888015200 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
72888015201 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
72888015205 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
72888015230 CLONAZEPAM clonazepam TABLET 0.5 mg Y Y N Quantity Limit
61269060510 KLONOPIN clonazepam TABLET 0.5 mg Y Y N Quantity Limit
00093321201 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
00093321205 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
00904772861 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
16729013700 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
16729013716 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
43547040710 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
43547040711 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
43547040750 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
49884049605 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
50268017411 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
50268017415 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
57664027408 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
57664027413 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
57664027418 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
59651072301 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
59651072399 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
60687087201 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
60687087211 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
62135077090 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
72603030801 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
72603030802 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
72603030803 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
72888015300 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
72888015301 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
72888015305 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
72888015330 CLONAZEPAM clonazepam TABLET 1 mg Y Y N Quantity Limit
61269061010 KLONOPIN clonazepam TABLET 1 mg Y Y N Quantity Limit
00093321301 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
00093321305 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
16729013800 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
16729013816 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
43547040810 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
43547040850 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
49884049705 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
50268017511 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
50268017515 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
57664027508 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
57664027513 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
57664027518 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
59651072401 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
59651072405 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
62135077190 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
72603030901 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
72603030902 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
72888015400 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
72888015401 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
72888015405 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
72888015430 CLONAZEPAM clonazepam TABLET 2 mg Y Y N Quantity Limit
00004009832 KLONOPIN clonazepam TABLET 2 mg Y Y N Quantity Limit
61269062010 KLONOPIN clonazepam TABLET 2 mg Y Y N Quantity Limit
13107028401 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 15 mg Y Y Quantity Limit
13107032101 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 15 mg Y Y Quantity Limit
51672404401 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 15 mg Y Y Quantity Limit
60505475601 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 15 mg Y Y Quantity Limit
62584068101 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 15 mg Y Y Quantity Limit
70954015710 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 15 mg Y Y Quantity Limit
70954015720 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 15 mg Y Y Quantity Limit
70954015730 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 15 mg Y Y Quantity Limit
70954015740 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 15 mg Y Y Quantity Limit
72603011401 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 15 mg Y Y Quantity Limit
13107028201 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 3.75 mg Y Y Quantity Limit
13107028205 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 3.75 mg Y Y Quantity Limit
13107031901 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 3.75 mg Y Y Quantity Limit
13107031905 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 3.75 mg Y Y Quantity Limit
51672404201 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 3.75 mg Y Y Quantity Limit
51672404202 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 3.75 mg Y Y Quantity Limit
60505475401 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 3.75 mg Y Y Quantity Limit
62584067901 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 3.75 mg Y Y Quantity Limit
70954015910 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 3.75 mg Y Y Quantity Limit
70954015930 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 3.75 mg Y Y Quantity Limit
70954015940 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 3.75 mg Y Y Quantity Limit
70954015950 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 3.75 mg Y Y Quantity Limit
72603011201 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 3.75 mg Y Y Quantity Limit
13107028301 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 7.5 mg Y Y Quantity Limit
13107028305 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 7.5 mg Y Y Quantity Limit
13107032001 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 7.5 mg Y Y Quantity Limit
13107032005 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 7.5 mg Y Y Quantity Limit
51672404301 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 7.5 mg Y Y Quantity Limit
51672404302 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 7.5 mg Y Y Quantity Limit
60505475501 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 7.5 mg Y Y Quantity Limit
62584068001 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 7.5 mg Y Y Quantity Limit
70954015810 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 7.5 mg Y Y Quantity Limit
70954015830 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 7.5 mg Y Y Quantity Limit
70954015840 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 7.5 mg Y Y Quantity Limit
70954015850 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 7.5 mg Y Y Quantity Limit
72603011301 CLORAZEPATE DIPOTASSIUM clorazepate dipotassium TABLET 7.5 mg Y Y Quantity Limit
00054318544 DIAZEPAM diazepam ORAL CONC 5 mg/mL Y Y Quantity Limit
62135076843 DIAZEPAM diazepam ORAL CONC 5 mg/mL Y Y Quantity Limit
00121090505 DIAZEPAM diazepam SOLUTION 5 mg/5 mL (1 mg/mL, 5 mL) Y Y Quantity Limit
00121090594 DIAZEPAM diazepam SOLUTION 5 mg/5 mL (1 mg/mL, 5 mL) Y Y Quantity Limit
00904711741 DIAZEPAM diazepam SOLUTION 5 mg/5 mL (1 mg/mL, 5 mL) Y Y Quantity Limit
00904711793 DIAZEPAM diazepam SOLUTION 5 mg/5 mL (1 mg/mL, 5 mL) Y Y Quantity Limit
60687075540 DIAZEPAM diazepam SOLUTION 5 mg/5 mL (1 mg/mL, 5 mL) Y Y Quantity Limit
60687075586 DIAZEPAM diazepam SOLUTION 5 mg/5 mL (1 mg/mL, 5 mL) Y Y Quantity Limit
62135076724 DIAZEPAM diazepam SOLUTION 5 mg/5 mL (1 mg/mL, 5 mL) Y Y Quantity Limit
62135076745 DIAZEPAM diazepam SOLUTION 5 mg/5 mL (1 mg/mL, 5 mL) Y Y Quantity Limit
68094075059 DIAZEPAM diazepam SOLUTION 5 mg/5 mL (1 mg/mL, 5 mL) Y Y Quantity Limit
68094075062 DIAZEPAM diazepam SOLUTION 5 mg/5 mL (1 mg/mL, 5 mL) Y Y Quantity Limit
00054318863 DIAZEPAM diazepam SOLUTION 5 mg/5 mL (1 mg/mL) Y Y Quantity Limit
00054820816 DIAZEPAM diazepam SOLUTION 5 mg/5 mL (1 mg/mL) Y Y Quantity Limit
62135076747 DIAZEPAM diazepam SOLUTION 5 mg/5 mL (1 mg/mL) Y Y Quantity Limit
00172392760 DIAZEPAM diazepam TABLET 10 mg Y Y Quantity Limit
00172392770 DIAZEPAM diazepam TABLET 10 mg Y Y Quantity Limit
00172392780 DIAZEPAM diazepam TABLET 10 mg Y Y Quantity Limit
00378047701 DIAZEPAM diazepam TABLET 10 mg Y Y Quantity Limit
00378047705 DIAZEPAM diazepam TABLET 10 mg Y Y Quantity Limit
51079028601 DIAZEPAM diazepam TABLET 10 mg Y Y Quantity Limit
51079028620 DIAZEPAM diazepam TABLET 10 mg Y Y Quantity Limit
59651065401 DIAZEPAM diazepam TABLET 10 mg Y Y Quantity Limit
59651065405 DIAZEPAM diazepam TABLET 10 mg Y Y Quantity Limit
59651065499 DIAZEPAM diazepam TABLET 10 mg Y Y Quantity Limit
62135078890 DIAZEPAM diazepam TABLET 10 mg Y Y Quantity Limit
00172392560 DIAZEPAM diazepam TABLET 2 mg Y Y Quantity Limit
00172392570 DIAZEPAM diazepam TABLET 2 mg Y Y Quantity Limit
00378027101 DIAZEPAM diazepam TABLET 2 mg Y Y Quantity Limit
00378027105 DIAZEPAM diazepam TABLET 2 mg Y Y Quantity Limit
51079028401 DIAZEPAM diazepam TABLET 2 mg Y Y Quantity Limit
51079028420 DIAZEPAM diazepam TABLET 2 mg Y Y Quantity Limit
59651065201 DIAZEPAM diazepam TABLET 2 mg Y Y Quantity Limit
59651065205 DIAZEPAM diazepam TABLET 2 mg Y Y Quantity Limit
62135078690 DIAZEPAM diazepam TABLET 2 mg Y Y Quantity Limit
00172392660 DIAZEPAM diazepam TABLET 5 mg Y Y Quantity Limit
00172392670 DIAZEPAM diazepam TABLET 5 mg Y Y Quantity Limit
00172392680 DIAZEPAM diazepam TABLET 5 mg Y Y Quantity Limit
00378034501 DIAZEPAM diazepam TABLET 5 mg Y Y Quantity Limit
00378034505 DIAZEPAM diazepam TABLET 5 mg Y Y Quantity Limit
51079028501 DIAZEPAM diazepam TABLET 5 mg Y Y Quantity Limit
51079028520 DIAZEPAM diazepam TABLET 5 mg Y Y Quantity Limit
59651065301 DIAZEPAM diazepam TABLET 5 mg Y Y Quantity Limit
59651065305 DIAZEPAM diazepam TABLET 5 mg Y Y Quantity Limit
59651065399 DIAZEPAM diazepam TABLET 5 mg Y Y Quantity Limit
62135078790 DIAZEPAM diazepam TABLET 5 mg Y Y Quantity Limit
52427065830 LOREEV XR lorazepam CAP ER 24H 1 mg Y Y Quantity Limit
52427066130 LOREEV XR lorazepam CAP ER 24H 1.5 mg Y Y Quantity Limit
52427066330 LOREEV XR lorazepam CAP ER 24H 2 mg Y Y Quantity Limit
52427066730 LOREEV XR lorazepam CAP ER 24H 3 mg Y Y Quantity Limit
00121077001 LORAZEPAM lorazepam ORAL CONC 2 mg/mL Y Y Quantity Limit
62135054943 LORAZEPAM lorazepam ORAL CONC 2 mg/mL Y Y Quantity Limit
65162068784 LORAZEPAM lorazepam ORAL CONC 2 mg/mL Y Y Quantity Limit
00054353244 LORAZEPAM INTENSOL lorazepam ORAL CONC 2 mg/mL Y Y Quantity Limit
00093342501 LORAZEPAM lorazepam TABLET 0.5 mg Y Y Quantity Limit
00093342505 LORAZEPAM lorazepam TABLET 0.5 mg Y Y Quantity Limit
00093342510 LORAZEPAM lorazepam TABLET 0.5 mg Y Y Quantity Limit
00904600761 LORAZEPAM lorazepam TABLET 0.5 mg Y Y Quantity Limit
13107008301 LORAZEPAM lorazepam TABLET 0.5 mg Y Y Quantity Limit
13107008305 LORAZEPAM lorazepam TABLET 0.5 mg Y Y Quantity Limit
62135086101 LORAZEPAM lorazepam TABLET 0.5 mg Y Y Quantity Limit
62559019505 LORAZEPAM lorazepam TABLET 0.5 mg Y Y Quantity Limit
62584076901 LORAZEPAM lorazepam TABLET 0.5 mg Y Y Quantity Limit
63304077201 LORAZEPAM lorazepam TABLET 0.5 mg Y Y Quantity Limit
63304077205 LORAZEPAM lorazepam TABLET 0.5 mg Y Y Quantity Limit
63304077210 LORAZEPAM lorazepam TABLET 0.5 mg Y Y Quantity Limit
64980062701 LORAZEPAM lorazepam TABLET 0.5 mg Y Y Quantity Limit
64980062750 LORAZEPAM lorazepam TABLET 0.5 mg Y Y Quantity Limit
69315090401 LORAZEPAM lorazepam TABLET 0.5 mg Y Y Quantity Limit
69315090405 LORAZEPAM lorazepam TABLET 0.5 mg Y Y Quantity Limit
69315090410 LORAZEPAM lorazepam TABLET 0.5 mg Y Y Quantity Limit
00093342601 LORAZEPAM lorazepam TABLET 1 mg Y Y Quantity Limit
00093342605 LORAZEPAM lorazepam TABLET 1 mg Y Y Quantity Limit
00093342610 LORAZEPAM lorazepam TABLET 1 mg Y Y Quantity Limit
00904600860 LORAZEPAM lorazepam TABLET 1 mg Y Y Quantity Limit
00904600861 LORAZEPAM lorazepam TABLET 1 mg Y Y Quantity Limit
13107008401 LORAZEPAM lorazepam TABLET 1 mg Y Y Quantity Limit
13107008405 LORAZEPAM lorazepam TABLET 1 mg Y Y Quantity Limit
13107008499 LORAZEPAM lorazepam TABLET 1 mg Y Y Quantity Limit
62135086201 LORAZEPAM lorazepam TABLET 1 mg Y Y Quantity Limit
62559019610 LORAZEPAM lorazepam TABLET 1 mg Y Y Quantity Limit
63304077301 LORAZEPAM lorazepam TABLET 1 mg Y Y Quantity Limit
63304077305 LORAZEPAM lorazepam TABLET 1 mg Y Y Quantity Limit
63304077310 LORAZEPAM lorazepam TABLET 1 mg Y Y Quantity Limit
64980062801 LORAZEPAM lorazepam TABLET 1 mg Y Y Quantity Limit
64980062850 LORAZEPAM lorazepam TABLET 1 mg Y Y Quantity Limit
69315090501 LORAZEPAM lorazepam TABLET 1 mg Y Y Quantity Limit
69315090505 LORAZEPAM lorazepam TABLET 1 mg Y Y Quantity Limit
69315090510 LORAZEPAM lorazepam TABLET 1 mg Y Y Quantity Limit
00093342701 LORAZEPAM lorazepam TABLET 2 mg Y Y Quantity Limit
00093342705 LORAZEPAM lorazepam TABLET 2 mg Y Y Quantity Limit
00093342710 LORAZEPAM lorazepam TABLET 2 mg Y Y Quantity Limit
00904600960 LORAZEPAM lorazepam TABLET 2 mg Y Y Quantity Limit
00904600961 LORAZEPAM lorazepam TABLET 2 mg Y Y Quantity Limit
13107008501 LORAZEPAM lorazepam TABLET 2 mg Y Y Quantity Limit
13107008505 LORAZEPAM lorazepam TABLET 2 mg Y Y Quantity Limit
62135086301 LORAZEPAM lorazepam TABLET 2 mg Y Y Quantity Limit
62559019701 LORAZEPAM lorazepam TABLET 2 mg Y Y Quantity Limit
63304077401 LORAZEPAM lorazepam TABLET 2 mg Y Y Quantity Limit
63304077405 LORAZEPAM lorazepam TABLET 2 mg Y Y Quantity Limit
63304077410 LORAZEPAM lorazepam TABLET 2 mg Y Y Quantity Limit
64980062901 LORAZEPAM lorazepam TABLET 2 mg Y Y Quantity Limit
64980062950 LORAZEPAM lorazepam TABLET 2 mg Y Y Quantity Limit
69315090601 LORAZEPAM lorazepam TABLET 2 mg Y Y Quantity Limit
69315090605 LORAZEPAM lorazepam TABLET 2 mg Y Y Quantity Limit
69315090610 LORAZEPAM lorazepam TABLET 2 mg Y Y Quantity Limit
00228206710 OXAZEPAM oxazepam CAPSULE 10 mg Y Y Quantity Limit
62584081201 OXAZEPAM oxazepam CAPSULE 10 mg Y Y Quantity Limit
62584081211 OXAZEPAM oxazepam CAPSULE 10 mg Y Y Quantity Limit
69315091101 OXAZEPAM oxazepam CAPSULE 10 mg Y Y Quantity Limit
00228206910 OXAZEPAM oxazepam CAPSULE 15 mg Y Y Quantity Limit
62584081301 OXAZEPAM oxazepam CAPSULE 15 mg Y Y Quantity Limit
62584081311 OXAZEPAM oxazepam CAPSULE 15 mg Y Y Quantity Limit
69315091201 OXAZEPAM oxazepam CAPSULE 15 mg Y Y Quantity Limit
00228207310 OXAZEPAM oxazepam CAPSULE 30 mg Y Y Quantity Limit
62584081401 OXAZEPAM oxazepam CAPSULE 30 mg Y Y Quantity Limit
62584081411 OXAZEPAM oxazepam CAPSULE 30 mg Y Y Quantity Limit
69315091301 OXAZEPAM oxazepam CAPSULE 30 mg Y Y Quantity Limit
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