Intranasal midazolam and rectal diazepam are both prescribed by neurologists to abort prolonged and clusters of seizures in the outpatient setting. Compared with rectal diazepam, intranasal midazolam is easier for families to use, has fewer side effects, and it is more cost-effective. The aim of our study is to determine if home use of intranasal midazolam impacts emergency department (ED) and unplanned hospital utilization for seizure care compared to rectally-administered diazepam. We queried a database from an accountable care organization, Partners for Kids (PFK), and found 12,629 patients with the diagnosis of epilepsy using ICD-9 codes 345.xx (epilepsy and recurrent seizures) or 780.39 (other convulsions). PFK is responsible for the care of over 300,000 children. In this retrospective study, we obtained data for 1,060 patients meeting our study’s inclusion and exclusion criteria. These patients were seen over a 5 year time period. Data elements included: demographics, ED visits, as well as number of midazolam and diazepam prescriptions. Overall, use of intranasal midazolam was not associated with increased ED utilization compared with use of rectal diazepam. For all ages, the normalized payment in the ED was higher for rectal diazepam (p < 0.0001). Analysis showed no difference for normalized inpatient payments or combined, normalized ED and inpatient payments. Age-matched analysis revealed that there was no significant difference between groups for ED utilization (p ¼ 0.0971). In summary, rectal diazepam was associated with higher overall health care costs. In addition, these findings support previous studies showing that both intranasal midazolam and rectal diazepam are viable treatment options for patients at risk for prolonged seizure events.