DIAZEPAM

DIAZEPAM (2669L)

diazepam 10 mg/10 mL oral liquid, 100 mL
2669L
Body System:
Manner of administration:Oral
General Schedule
Authority Required

Restriction

Indication: Chronic spasticity
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 1 # of repeats: 0 DPMQ: $45.26 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Diazepam Elixir

DIAZEPAM (3161J)

diazepam 2 mg tablet, 50
3161J
Body System:
Manner of administration:Oral
General Schedule
No restrictions
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 50 # of repeats: 0 DPMQ: $17.10 Max safety net: $18.64 General Patient Charge: $21.43
Available brands
APX-Diazepam
DIAZEPAM-WGR
Valpam 2
Antenex 2
*Additional charge for this brand is $2.78
 DPMQ: $19.88 Max safety net: $18.64 General Patient Charge: $24.21

DIAZEPAM (3162K)

diazepam 5 mg tablet, 50
3162K
Body System:
Manner of administration:Oral
General Schedule
No restrictions
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 50 # of repeats: 0 DPMQ: $17.10 Max safety net: $18.64 General Patient Charge: $21.43
Available brands
APX-Diazepam
Antenex 5
DIAZEPAM-WGR
Valpam 5
Valium
*Additional charge for this brand is $3.07
 DPMQ: $20.17 Max safety net: $18.64 General Patient Charge: $24.50

DIAZEPAM (5071X)

diazepam 2 mg tablet, 50
5071X
Body System:
Manner of administration:Oral
General Schedule
No restrictions
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 50 # of repeats: 0 DPMQ: $17.10 Max safety net: $18.64 General Patient Charge: $21.43
Available brands
APX-Diazepam
DIAZEPAM-WGR
Valpam 2
Antenex 2
*Additional charge for this brand is $2.78
 DPMQ: $19.88 Max safety net: $18.64 General Patient Charge: $24.21

DIAZEPAM (5072Y)

diazepam 5 mg tablet, 50
5072Y
Body System:
Manner of administration:Oral
General Schedule
No restrictions
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 50 # of repeats: 0 DPMQ: $17.10 Max safety net: $18.64 General Patient Charge: $21.43
Available brands
APX-Diazepam
Antenex 5
DIAZEPAM-WGR
Valpam 5
Valium
*Additional charge for this brand is $3.07
 DPMQ: $20.17 Max safety net: $18.64 General Patient Charge: $24.50

DIAZEPAM (5355W)

diazepam 2 mg tablet, 50
5355W
Body System:
Manner of administration:Oral
Palliative Care
Authority Required

Restriction

Indication: Anxiety
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 50 # of repeats: 3 DPMQ: $17.10 Max safety net: $18.64 General Patient Charge: $21.43
Available brands
APX-Diazepam
DIAZEPAM-WGR
Valpam 2
Antenex 2
*Additional charge for this brand is $2.78
 DPMQ: $19.88 Max safety net: $18.64 General Patient Charge: $24.21

DIAZEPAM (5356X)

diazepam 5 mg tablet, 50
5356X
Body System:
Manner of administration:Oral
Palliative Care
Authority Required

Restriction

Indication: Anxiety
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 50 # of repeats: 3 DPMQ: $17.10 Max safety net: $18.64 General Patient Charge: $21.43
Available brands
APX-Diazepam
Antenex 5
DIAZEPAM-WGR
Valpam 5
Valium
*Additional charge for this brand is $3.07
 DPMQ: $20.17 Max safety net: $18.64 General Patient Charge: $24.50