The following lists of drugs are age restricted or age and gender restricted.

Note: This table includes Wisconsin Medicaid’s most current information and may be updated periodically. Certain drugs listed in this table are registered or trademarked by the manufacturer.

Age-Restricted Drugs
Product	Allowable Ages
Certain HealthCheck "Other Services" (e.g., iron supplements, multivitamins)	Under 21 years of age
Iron Products	Under 60 years of age
Synagis®	Under two years of age*

*Prescribers may submit a claim for Synagis® for recipients older than two years of age. The claim must be submitted on the 837 Health Care Claim: Professional transaction. Providers are required to indicate Current Procedural Terminology code 90378 (Respiratory syncytial virus immune globulin [RSV-IgIM], for intramuscular use, 50 mg, each), with the appropriate unit that indicates administered dosage (e.g., 1 unit equals 50 mg) on each claim submission.

Age- and Gender-Restricted Drugs
Product	Allowable Recipients	Allowable Ages
Oral Contraceptives	Females	12 to 60 years of age
Prenatal Vitamins	Females	12 to 60 years of age

Attachment 1: Brand Medically Necessary Drugs That Require Prior Authorization
Attachment 2: Brand Medically Necessary Prior Authorization Documentation
Attachment 3: MedWatch Reporting Form (FDA Web site) (PDF, 53 KB)
Attachment 4: Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) Drugs
Attachment 5: Drug Products Requiring Paper Prior Authorization
Attachment 6: Diagnosis-Restricted Drugs (Organized by Generic Drug Name)
Attachment 7: Diagnosis-Restricted Drugs (Organized by Diagnosis Code Description)
Attachment 8: Covered Over-the-Counter Drugs
Attachment 9: Noncovered Drugs
Attachment 11: Covered Over-the-Counter Drugs for HealthCheck "Other Services"
Attachment 12: Comparison of Wisconsin Medicaid and Wisconsin SeniorCare Policies
Attachment 13: Obsolete 1/1/05: STAT-PA Drug Worksheet for Brand Name Clozaril^® — Use Prior Authorization / Brand Medically Necessary Attachment (PA/BMNA) (fillable PDF, 225 KB)  | Instructions (PDF, 71 KB)

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