© 2021 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2021.01 pg. 1 www.prescryptive.com AGE LIMIT RESTRICTIONS Below is a list of medications with an age limit restriction requiring prior authorization by your plan. This list is intended only as a guide to coverage. We encourage you to talk to your doctor about all of your treatment options. To learn more about your benefit plan coverage, check your specific plan documents available by logging in to your member portal at www.prescryptive.com/member. Acne Products Under age 12 Under age 12 Over age 35 Over age 35 Over age 35 Over age 35 Over age 35 Over age 35 Over age 35 Over age 35 Over age 35 Over age 35 Over age 35 Over age 35 Over age 35 Over age 35 Over age 35 Over age 35 Over age 35 Over age 35 Over age 35 Aczone Gel 5% Aczone Gel 7.5% Adapalene Cream 0.1% Adapalene Gel 0.1% Adapalene Pad 0.1% Swab Adapalene Solution 0.1% Aklief Cream 0.005% Altreno Lotion 0.05% Arazlo Lotion 0.045% Atralin Gel 0.05% Avita Cream 0.025% Avita Gel 0.025% Clindamycin Gel - Tretinoin Differin Gel 0.3% Differin Lotion 0.1% Epiduo Forte Gel 0.3-2.5% Epiduo Gel 0.1-2.5% Fabior AeroSolution 0.1% Retin-A Cream 0.05% Retin-A Cream 0.1% Retin-A Gel 0.01% Drug Name Therapeutic Category Prior Authorization Required For Dapsone Gel 5% Dapsone Gel 7.5% Adapalene Cream 0.1% Adapalene Gel 0.1% Adapalene Pad 0.1% Adapalene Solution 0.1% Trifarotene Cream 0.005% Tretinoin Lotion 0.05% Tazarotene Lotion 0.045% Tretinoin Gel 0.05% Tretinoin Cream 0.025% Tretinoin Gel 0.025% Clindamycin Phosphate - Tretinoin Gel 1.2-0.025% Adapalene Gel 0.3% Adapalene Lotion 0.1% Adapalene-Benzoyl Peroxide Gel 0.3-2.5% Adapalene-Benzoyl Peroxide Gel 0.1-2.5% Tazarotene Foam 0.1% Tretinoin Cream 0.05% Tretinoin Cream 0.1% Tretinoin Gel 0.01% Active Ingredient Name and Strength
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© 2021 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2021.01
pg. 1 www.prescryptive.com
AGE LIMIT RESTRICTIONSBelow is a list of medications with an age limit restriction requiring prior authorization by your plan. This list is intended only as a guide to coverage. We encourage you to talk to your doctor about all of your treatment options. To learn more about your benefit plan coverage, check your specific plan documents available by logging in to your member portal at www.prescryptive.com/member.
Acne Products Under age 12Under age 12Over age 35Over age 35Over age 35Over age 35Over age 35Over age 35Over age 35Over age 35Over age 35Over age 35Over age 35
Over age 35Over age 35Over age 35
Over age 35
Over age 35Over age 35Over age 35Over age 35
Aczone Gel 5%Aczone Gel 7.5%Adapalene Cream 0.1%Adapalene Gel 0.1%Adapalene Pad 0.1% SwabAdapalene Solution 0.1%Aklief Cream 0.005%Altreno Lotion 0.05%Arazlo Lotion 0.045%Atralin Gel 0.05%Avita Cream 0.025%Avita Gel 0.025%Clindamycin Gel - Tretinoin
Differin Gel 0.3%Differin Lotion 0.1%Epiduo Forte Gel 0.3-2.5%
Epiduo Gel 0.1-2.5%
Fabior AeroSolution 0.1%Retin-A Cream 0.05%Retin-A Cream 0.1%Retin-A Gel 0.01%
Drug NameTherapeuticCategory
Prior AuthorizationRequired For
Dapsone Gel 5%Dapsone Gel 7.5%Adapalene Cream 0.1%Adapalene Gel 0.1%Adapalene Pad 0.1%Adapalene Solution 0.1%Trifarotene Cream 0.005%Tretinoin Lotion 0.05%Tazarotene Lotion 0.045%Tretinoin Gel 0.05%Tretinoin Cream 0.025%Tretinoin Gel 0.025%Clindamycin Phosphate -Tretinoin Gel 1.2-0.025%
Adapalene Gel 0.3%Adapalene Lotion 0.1%Adapalene-Benzoyl PeroxideGel 0.3-2.5%
Adapalene-Benzoyl PeroxideGel 0.1-2.5%
Tazarotene Foam 0.1%Tretinoin Cream 0.05%Tretinoin Cream 0.1%Tretinoin Gel 0.01%
Active Ingredient Nameand Strength
© 2021 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2021.01
pg. 2 www.prescryptive.com
Acne Products(cont.)
Antiasthmatic and Bronchodilator Agents
Antidepressants
Antihyperlipidemics
Anti-Infective Agents
Over age 35Over age 35Over age 35Over age 35Over age 35Over age 35Over age 35Over age 35Over age 35Over age 35Over age 35Over age 35
Under age 5Under age 5Under age 12Under age 12
Over age 12
Over age 12
Over age 12
Over age 12
Under age 5
Retin-A Kit 0.01%Retin-A Kit 0.025%Retin-A Kit 0.025%Retin-A Kit 0.05%Retin-A Kit 0.1%Retin-A Liquid 0.05%Retin-A Micro Gel 0.04%Retin-A Micro Gel 0.06%Retin-A Micro Gel 0.08%Retin-A Micro Gel 0.1%Tretin-X Cream 0.0375%Tretin-X Cream 0.075%Winlevi Cream 1%
Accolate Tablet 10mgZafirlukast Tablet 20mgZyflo CR Tablet 600mgZyflo Tablet 600mg
Nortriptyline Solution10mg/5ml
Flolipid Suspension20mg/5ml
Flolipid Suspension40mg/5ml
Furadantin Suspension25mg/5ml
Relenza Mis Diskhale
Drug Name Prior AuthorizationRequired For
Tretinoin Gel 0.01% KitTretinoin Cream 0.025% KitTretinoin Gel 0.025% KitTretinoin Cream 0.05% KitTretinoin Cream 0.1% KitTretinoin Liquid 0.05%Tretinoin Microsphere Gel 0.04%
Tretinoin Microsphere Gel 0.06%
Tretinoin Microsphere Gel 0.08%
Tretinoin Microsphere Gel 0.1%Tretinoin Cream 0.0375%Tretinoin Cream 0.075%
Over age 35 Clascoterone Cream 1%
Zafirlukast Tablet 10 mgZafirlukast Tablet 20 mgZileuton Tablet ER 600 mgZileuton Tablet 600 mg
Nortriptyline HCl Solution10 mg/5ml
Simvastatin Suspension20 mg/5ml 4 mg/ml
Simvastatin Suspension40 mg/5ml 8 mg/ml
Nitrofurantoin Suspension25 mg/5ml
Zanamivir Aero PowderBreath Activated 5 mg/Blister
Active Ingredient Nameand Strength
TherapeuticCategory
© 2021 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2021.01
pg. 3 www.prescryptive.com
AntimyasthenicAgents
AntineoplasticsAnd AdjunctiveTherapies
Benzodiazepines
Over age 12
Over age 12
Over age 12
Under age 12
Under age 12Under age 12
Under age 12
Under age 12
Under age 12
Under age 12
Under age 6
Under age 6
Under age 6
Under age 9
Under age 9
Mestinon Solution 60mg/5ml
Mestinon Syrup 60mg/5ml
Xatmep Solution 2.5mg/ml
Alprazolam Concentrate1 mg/ml
Alprazolam Solution 0.5mg/5Alprazolam Tablet 0.25Orally Disintegrating Tablet
Alprazolam Tablet 0.5mgOrally Disintegrating Tablet
Alprazolam Tablet 1mgOrally Disintegrating Tablet
Alprazolam Tablet 2mgAlprazolam Tablet 2mgOrally Disintegrating Tablet
ChlordiazepoxideCapsule 10mg
Chlordiazepoxide Capsule 25mg
Chlordiazepoxide Capsule 5mg
Clorazepate DipotassiumCapsule 15mg
Clorazepate DipotassiumCapsule 3.75mg
Drug Name Prior AuthorizationRequired For
Pyridostigmine BromideOral Solution 60 mg/5ml
Pyridostigmine BromideSyrup 60 mg/5ml
Methotrexate Oral Solution2.5 mg/ml
Alprazolam Concentrate1 mg/ml
Alprazolam Solution 0.5 mg/5ml
Alprazolam OrallyDisintegrating Tablet 0.25 mg
Alprazolam Orally Disintegrating Tablet 0.5 mg
Alprazolam OrallyDisintegrating Tablet 1 mg
Alprazolam Tablet 2 mgAlprazolam OrallyDisintegrating Tablet 2 mg
ChlordiazepoxideHCl Capsule 10 mg
ChlordiazepoxideHCl Capsule 25 mg
ChlordiazepoxideHCl Capsule 5 mg
Clorazepate DipotassiumCapsule 15 mg
Clorazepate DipotassiumCapsule 3.75 mg
Active IngredientName and Strength
TherapeuticCategory
© 2021 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2021.01
pg. 4 www.prescryptive.com
Benzodiazepines(cont.)
Under age 9
Under age 9
Under age 9
Under age 9
Under age 15Under age 15Under age 18Under age 18Under age 18Under age 18Under age 18Under age 18Under age 18Under age 6Under age 6Under age 6Under age 12
Under age 12Under age 12Under age 12Under age 12Under age 12Under age 12Under age 12Under age 18
Clorazepate DipotassiumCapsule 7.5mg
Clorazepate DipotassiumTablet 15mg
Clorazepate DipotassiumTablet 3.75mg
Clorazepate DipotassiumTablet 7.5mg
Dalmane Capsule 15mgDalmane Capsule 30mgDoral Tablet 15mgDoral Tablet 7.5mgEstazolam Tablet 1mgEstazolam Tablet 2mgHalcion Tablet 0.125mgHalcion Tablet 0.25mgHalcion Tablet 0.5mgLibritabs Tablet 10mgLibritabs Tablet 25mgLibritabs Tablet 5mg
Lorazepam Concentrate2mg/ml
Lorazepam Tablet 0.5mg
Lorazepam Tablet 1mgLorazepam Tablet 2mgOxazepam Capsule 10mgOxazepam Capsule 15mgOxazepam Capsule 30mgOxazepam Tablet 15mgRestoril Capsule 15mg
Drug Name Prior AuthorizationRequired For
Clorazepate DipotassiumCapsule 7.5 mg
Clorazepate DipotassiumTablet 15 mg
Clorazepate DipotassiumTablet 3.75 mg
Clorazepate DipotassiumTablet 7.5 mg
Flurazepam HCl Capsule 15 mgFlurazepam HCl Capsule 30 mgQuazepam Tablet 15 mgQuazepam Tablet 7.5 mgEstazolam Tablet 1 mgEstazolam Tablet 2 mgTriazolam Tablet 0.125 mgTriazolam Tablet 0.25 mgTriazolam Tablet 0.5 mgChlordiazepoxide Tablet 10 mgChlordiazepoxide Tablet 25 mgChlordiazepoxide Tablet 5 mgLorazepam Concentrate2 mg/ml
Lorazepam Tablet 0.5 mgLorazepam Tablet 1 mgLorazepam Tablet 2 mgOxazepam Capsule 10 mgOxazepam Capsule 15 mgOxazepam Capsule 30 mgOxazepam Tablet 15 mgTemazepam Capsule 15 mg
Active Ingredient Nameand Strength
TherapeuticCategory
© 2021 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2021.01
pg. 5 www.prescryptive.com
Benzodiazepines(cont.)
GenitourinaryAgents
Migraine Products
MusculoskeletalTherapy Agents
Under age 18Under age 18Under age 18Under age 9
Under age 18Under age 18Under age 18Under age 18Under age 18Under age 18Under age 18
Under age 50Under age 50
Under age 18
Under age 18
Under age 18
Under age 18
Under age 18Under age 18
Under age 16
Restoril Capsule 22.5mg
Restoril Capsule 30mg
Restoril Capsule 7.5mg
Tranxene SD Tablet 22.5mg
Xanax Tablet 0.25mg
Xanax Tablet 0.5mg
Xanax Tablet 1mg
Xanax XR Tablet 0.5mg
Xanax XR Tablet 1mg
Xanax XR Tablet 2mg
Xanax XR Tablet 3mg
Dutasteride Capsule 0.5mg
Proscar Tablet 5mg
Nurtec Tablet 75mgOrally Disintegrating Tablet
Onzetra Xsail 11mg
Reyvow Tablet 100mg
Reyvow Tablet 50mg
Ubrelvy Tablet 100mg
Ubrelvy Tablet 50mg
Carisoprodol, Aspirin &Codeine Tablet 200-325-16 mg
Drug NameTherapeuticCategory
Prior AuthorizationRequired For
Temazepam Capsule 22.5 mgTemazepam Capsule 30 mgTemazepam Capsule 7.5 mgClorazepate DipotassiumTablet CR 22.5 mg
Alprazolam Tablet 0.25 mgAlprazolam Tablet 0.5 mgAlprazolam Tablet 1 mgAlprazolam Tablet ER 0.5 mgAlprazolam Tablet ER 1 mgAlprazolam Tablet ER 2 mgAlprazolam Tablet ER 3 mg
Dutasteride Capsule 0.5 mgFinasteride Tablet 5 mg
Rimegepant Sulfate OrallyDisintegrating Tablet 75 mg
Sumatriptan SuccinateExhaler Powder 11 mg
Lasmiditan SuccinateTablet 100 mg
Lasmiditan SuccinateTablet 50 mg
Ubrogepant Tablet 100 mgUbrogepant Tablet 50 mg
Carisoprodol, Aspirin &Codeine Tablet 200-325-16 mg
Active Ingredient Nameand Strength
© 2021 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2021.01
pg. 6www.prescryptive.com
PsychotherapeuticAnd NeurologicalAgents
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Donepezil Tablet 5mg
Donepezil Tablet 10mg
Donepezil Tablet 23mg
Donepezil Tablet 5mgOrally Disintegrating Tablet
Donepezil Tablet 10mgOrally Disintegrating Tablet
Galantamine Tablet 4mg
Galantamine Tablet 8mg
Galantamine Tablet 12mg
Galantamine Solution 4mg/ml
Galantamine Capsule 8mg ER
Galantamine Capsule 16mg ER
Galantamine Capsule 24mg ER
Exelon Patch 4.6mg/24 hour
Exelon Patch 9.5mg/24 hour
Exelon Patch 13.3/24 hour
Drug Name Prior AuthorizationRequired For
Donepezil Hydrochloride Tablet5 mg
Donepezil Hydrochloride Tablet10 mg
Donepezil Hydrochloride Tablet23 mg
Donepezil Hydrochloride OrallyDisintegrating Tablet 5 mg
Donepezil Hydrochloride OrallyDisintegrating Tablet 10 mg
Galantamine HydrobromideTablet 4 mg
Galantamine HydrobromideTablet 8 mg
Galantamine HydrobromideTablet 12 mg
Galantamine HydrobromideOral Solution 4 mg/ml
Galantamine HydrobromideCapsule ER 8 mg
Galantamine HydrobromideCapsule ER 16 mg
Galantamine HydrobromideCapsule ER 24 mg
Rivastigmine TD Patch4.6 mg/24 hour
Rivastigmine TD Patch9.5 mg/24 hour
Rivastigmine TD Patch13.3 mg/24 hour
Active IngredientName and Strength
TherapeuticCategory
© 2021 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2021.01 pg. 7
www.prescryptive.com
Psychotherapeutic And Neurological Agents (cont.)
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Under age 50
Exelon Capsule 1.5mg
Exelon Capsule 3mg
Exelon Capsule 4.5mg
Exelon Capsule 6mg
Memantine HCl Tablet5mg
Memantine HCl Tablet10mg
Namenda Tablet 5-10mgTitration Pack
Memantine Solution10mg/5ml
Memantine HCl Capsule7mg ER
Memantine HCl Capsule14mg ER
Memantine HCl Capsule21mg ER
Memantine HCl Capsule28mg ER
Namenda XR CapsuleTitration Pack
Namzaric Capsule 7-10mg
Namzaric Capsule 14-10mg
Drug Name Prior AuthorizationRequired For
Rivastigmine Tartrate Capsule1.5 mg
Rivastigmine Tartrate Capsule3 mg
Rivastigmine Tartrate Capsule4.5 mg
Rivastigmine Tartrate Capsule6 mg
Memantine HCl Tablet 5 mg
Memantine HCl Tablet 10 mg
Memantine HCl Tablet 28 x 5 mg& 21 x 10 mg Titration Pack
Memantine HCl Oral Solution2 mg/ml
Memantine HCl Capsule ER7 mg
Memantine HCl Capsule ER14 mg
Memantine HCl Capsule ER21 mg
Memantine HCl Capsule ER28 mg
Memantine HCl Capsule ER7 mg & 14 mg & 21 mg & 28 mgTitration Pack
Memantine HCl-Donepezil HClCapsule ER 7-10 mg
Memantine HCl-Donepezil HCl Capsule ER 14-10 mg
Active IngredientName and Strength
TherapeuticCategory
© 2021 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2021.01 pg. 8
www.prescryptive.com
Psychotherapeutic And Neurological Agents (cont.)
Under age 50
Under age 50
Under age 50
Namzaric Capsule 21-10mg
Namzaric Capsule 28-10mg
Namzaric CapsuleTitration Pack
Drug Name Prior AuthorizationRequired For
Memantine HCl-Donepezil HCl Capsule ER 21-10 mg
Memantine HCl-Donepezil HClCapsule ER 28-10 mg
Memantine-Donepezil CapsuleER 7 & 14 & 21 & 28-10 mgTitration Pack
Active IngredientName and Strength
TherapeuticCategory
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