15-Day Specialty Drug Limitation Program
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Defines a program that limits initial fills of specified specialty drugs to a 15-day supply for the first six fills, describes member cost-sharing for 15- vs 30-day supplies, and notes potential prior authorization requirements. Applies to Blue Care Network of Michigan members covered under the payer's benefit plans.
No material clinical or coverage changes in this revision.
Coverage rules for the 15‑day specialty drug program
15-day supply limitation and member cost-sharing
Coverage and dispensing rules for drugs in the 15-day program:
Do not flatten; these conditions apply together
The policy does not define any clinical exclusions. Instead of listing excluded conditions or diagnoses, the document provides a multi-page alphabetical list of specialty drugs included in the 15-day program (for example: Afinitor, Talzenna, Iclusig, Imbruvica, Nerlynx, Tabrecta, Gavreto, etc.). This list is the operative inclusion mechanism for the program and should be used to determine which products are subject to the day‑supply rules.
Because inclusion is determined by the published drug list rather than by explicit clinical exclusions, reviewers and dispensing pharmacists should check the program drug list when assessing whether the 15‑day limitation applies to a given prescription.
Initial fill day-supply limit (first six fills)
Initial therapy day-supply limit
Initial fill rule:
Member pays half copay for 15-day supply
Continuation therapy (7th fill and beyond)
Continuation fills (7th fill and beyond)
Continuation/ongoing fill rule after initial limited fills:
Member cost-sharing differs by supply length
What providers must do / watch for
Obtain prior authorization when required
Some drugs included in the 15-day program may require prior authorization; obtain prior authorization per payer procedures before dispensing when indicated.
Day-supply limit (not step therapy)
This program limits the days' supply for listed specialty drugs (15-day supply for each of the first six fills) rather than requiring trials of alternate agents. Do not interpret the policy as step-therapy.
Document six 15-day fills to qualify for 30-day supply
To qualify for up to a 30-day supply after the initial period, document that the member has had six 15-day supply prescriptions filled within the last six months.
- Record fill dates and quantity for each of the six 15-day fills within the past six months.
- Include pharmacy dispensing records or insurer adjudication history showing six qualifying fills.
Risk of claim denial for excess day-supply or missing PA
Claims for supplies exceeding the permitted day-supply in the first six fills, or claims for drugs that require prior authorization when PA was not obtained, may be denied or limited.
- Verify day-supply on the claim does not exceed 15 days for fills 1–6.
- Confirm a valid prior authorization exists before submitting the claim when required.
Program-wide quantity limits
Key definitions
Site-of-care considerations
Site‑of‑care not specified
The policy does not specify or require a particular site of care for dispensing these drugs.
Background and intent
This program is an administrative utilization management action designed to reduce member out‑of‑pocket copayment burden and medication waste by limiting early fills of selected high‑cost specialty drugs to shorter supplies. The design limits the day supply for each of the first six fills to 15 days, with different member cost‑sharing for 15‑day versus 30‑day supplies and allowance for a longer supply after meeting the program’s fill requirements.
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