Prescription Coverage - Quantity & Age Limitations

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» About Quantity & Age Limitations
» Quantity & Age Limitations Covered Medications

Other Prescription Management Controls:
» Prior Authorizations: Click Here
» Exclusions: Click Here
» Quantity & Age Limitations: Click Here
» Specialty Medications: Click Here
» Step Therapies: Click Here
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About Quantity & Age Limitations

Certain prescriptions require Prior Authorization (approval from the Health Plan) before they will be covered. Types of Prior Authorizations include, but are not limited to, prescriptions which exceed recommended quantity limitations, exceed recommended age limitations, and/or require clinical determinations for appropriate use. The Health Plan’s prescription drug program vendor administers the Quantity & Age Limitation process on behalf of the Health Plan. A listing of prescription medications with Quantity or Age Limitations are listed below:
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Disclaimer: The Health Plan reserves the right to add or remove medications from this list at any time, so please contact the Health Plan Administration office to verify whether a covered medication is subject to a Clinical Prior Authorization (CPA).
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Quantity & Age Limitation Covered 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
» Glucometers - One Per Year

Compounds
» $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, so please contact the Health Plan Administration office to verify whether a covered medication is subject to a Clinical Prior Authorization (CPA).
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