Quantity & Age Limitations
Prescription Management Program

Certain medications require Prior Authorization (approval from the Health Plan) before they will be covered. Types of Prior Authorizations include, but are not limited to, medications which exceed recommended quantity limitations, exceed recommended age limitations, and/or require clinical determinations for appropriate use. The Health Plan’s prescription vendor administers the Quantity & Age Limitation process on behalf of the Health Plan.
Impacted Medications
Acne Medications (Topical) such as Tretinoins (Retin A) for ages 26 and older
Analgesics (Opioids) such as Oxycontin
Anaphylaxis Therapy such as Epipen
Antiemetics such as Emend
Anti-fungal Agents such as Lamisil
Blood Glucose Monitoring Devices such as Glucometers - One Per Year
Compounds up to $300 Maximum Limit Per Script
Influenza Agents such as Tamiflu
Insomnia Hypnotics or Sleep Aids such as Zolpidem (generic name for Ambien)
Migraine Agents such as Sumatriptan (generic name for Imitrex)
Non-Steroidal Anti-Inflammatory Drugs such as Keterolac (generic name for Toradol)
Tobacco Cessation such as Chantix, Bupropion (generic name for Zyban) and over-the-counter gum, lozenges and patches, with a prescription. Limited to 2 sessions or 180 days per year. E-Cigarettes, Nasal sprays or inhalers used for tobacco cessation are excluded.
Disclaimer: The Health Plan reserves the right to add or remove medications from this list at any time. Contact the Health Plan Administration Office to verify whether a covered medication is subject to a Quantity or Age Limitation.