Making Healthy Cheaper
Rx - Quantity & Age Restrictions

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:


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 a Quantity or Age Restriction.

  Quantity or Age Restriction Medications
      Acne Medications (Topical) such as:
            Tretinoins (Retin A) for ages 26 and older
      Analgesics (Opioids) such as:
      Anaphylaxis Therapy such as:
      Antiemetics such as:
      Anti-fungal Agents such as:
      Blood Glucose Monitoring Devices such as:
            Glucometers - One Per Year
      Compounds, up to $300 Maximum Limit Per Script
      Influenza Agents such as:
      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:
            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