Quantity & Age Limitations
Prescription Management Program

Certain medications require Prior Authorization approval from the OPEH&W 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 OPEH&W Health Plan’s prescription vendor administers the Quantity & Age Limitation process on behalf of the OPEH&W Health Plan.

Use the following links to access the Express Scripts (ESI) Formulary for each health coverage option:
   Diamond https://www.express-scripts.com/DIAMOND Link
   Platinum https://www.express-scripts.com/PLATINUM Link
   Gold https://www.express-scripts.com/GOLD Link
   Silver https://www.express-scripts.com/SILVER Link
   Bronze https://www.express-scripts.com/BRONZE Link
The OPEH&W Health Plan reserves the right to adjust this list from time to time as required
If in doubt, contact the Health Plan Administration Office to verify whether a covered medication is subject to Exclusion

Quantity & Age Limitation 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)
   》Gum - Over-The-Counter
   》Requires a prescription
   》Limited to 2 sessions or 180 days per year
   》E-Cigarettes, Nasal sprays or inhalers used for tobacco cessation are excluded