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CurrentBlue Cross Blue Shield - IllinoisPolicy N/A

Balanced Dispensing Limits (Pharmacy Coverage Criteria)

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Defines quantity and time-period dispensing limits for specified prescription drugs (brands and generics) under BCBSIL pharmacy benefits; affects prescribers, pharmacies, and members covered by BCBSIL (state-specific variations may apply).

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyBalanced Dispensing Limits (Pharmacy Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify and adhere to the listed per-product dispensing limits; obtain prior authorization if requesting quantities above the listed limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~120+distinct product lines listed

2common per-28/30-day limit for many biologics/pen products

100 mLtypical per-30-day insulin volume

300pen needles per 30 days (cumulative)

Coverage Criteria and Quantity Limits

General coverage rule

Coverage is allowed up to the listed dispensing limit for each medication; quantities beyond the listed limit are the member's financial responsibility unless plan exceptions apply.

General dispensing rule: Coverage is limited to the specific quantity and time-period listed for each drug (e.g., tablets, mLs, syringes, pens, kits).per-entry limits as specified

Members may obtain larger quantities but will pay full cost beyond coverage; some limits vary by state or plan.

Product-level dispensing limits (examples)

Examples from the list (not exhaustive in this extract):

Specific examples: abacavir sulfate soln 20 mg/mL = 960 mLs per 30 days; abacavir sulfate tab 300 mg = 60 tablets per 30 days; abaloparatide pen 3120 mcg/1.56 mL (Tymlos) = 1.56 mLs (1 injection) per 30 days; abatacept prefilled syringes (Orencia) = 4 syringes per 28 days; adalimumab products = typically 2 pens or 2 syringes per 28 days or starter kits 1 kit per 180 days, depending on product variant.

Coding, Examples and Special Calculations

Provider Actions, Authorization and Billing Notes

Prior Authorization

Prior Authorization and Over‑Limit Requests

Dispensing limits listed in this policy govern coverage quantities; requests that exceed the stated per-prescription or per-period dispensing limits may require prior authorization or may be denied. If a prescriber submits a request above the listed limit, confirm plan-specific PA requirements — some exceptions may be allowed with documented medical necessity.

Dispensing limit may require prior authorization if exceeded.
Dispensing limits govern need for authorization — check member plan details or ID card.

Note

PA Not Specified in This Segment

This section of the dispensing limits list does not, by itself, define a universal prior authorization rule for all products. Some entries include explicit notes about refill windows or fill limits (for example, GLP‑1 agents and injectable biologics), but the presence or absence of an explicit PA statement in an item does not replace plan‑specific PA rules.

Prior authorization not specified in this segment — informational only.

Background and Rationale

Dispensing limits are administrative controls intended to promote appropriate use and manage supply. They set maximum covered quantities per prescription or per defined time windows and are applied to plan pharmacy benefits; limits may vary by plan and state and are subject to change.

Definitions and Terms

inv-90: Dispensing Limit definition

DefinitionDispensing Limit: coverage cap on quantity of medication allowed per prescription or within a defined time period (e.g., per 30, 28, or 180 days)

Outcome if exceededIf prescribed quantity exceeds the dispensing limit, the member may obtain medication but will be responsible for full cost beyond coverage

Plan variation noteSome dispensing limits may not apply to all members or may vary by state regulations; verify plan materials

inv-91: Brand/Generic applicability codes (BG/B/G)

BG / B / G codesBG = Brand and Generic applicable; B = Brand only; G = Generic only (designation shown per product line)

UsageEach product line in the list includes a BG/B/G designation to indicate substitution/applicability

Step Therapy and Special Fill Limits

Step/Restriction	Description	Refill window / Notes
A fill limit permitting only one injectable GLP-1 agent and one strength per 28 days
A fill limit permitting only one oral GLP-1 agent and one strength per 28 days (applies to liraglutide)
Pharmacy claims must conform to the single-agent/strength fill limit; quantities beyond the limit may be denied or require authorization

Per-Product Quantity Limits (Selected Entries)

inv-104: abacavir sulfate soln 20 mg/ml (Ziagen) — 960 mLs

Abacavir solution limitabacavir sulfate solution 20 mg/mL (Ziagen) — 960 mLs per 30 DAYS

DesignationListed as BG (brand and generic applicability) in the policy entry

ContextExample of mL-per-30-day expression used for liquid antiretroviral formulations

inv-105: abacavir sulfate tab 300 mg (Ziagen) — 60 Tablets

Abacavir tablet limitabacavir sulfate 300 mg tablets (Ziagen) — 60 Tablets per 30 DAYS

DesignationListed as BG in the policy entry

Context

Selected Device Limits and Coding-Related Notes

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyBalanced Dispensing Limits (Pharmacy Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify and adhere to the listed per-product dispensing limits; obtain prior authorization if requesting quantities above the listed limits.

SourceLink

On This Page

as listed per product

Brand/generic applicability indicated per line (B/G/BG).

Quantity limit based coverage

Covered when dispensed within the stated quantity limits per product and time period

Per-product dispensing limits: Each listed product is subject to the exact dispensing limit shown (examples include biologics: 2 pens/syringes per 28 days; inhalers: commonly 2–3 inhalers per 30 days; many oral agents: typically 30 tablets per 30 days).see product entries

Product-specific limits detailed in document chunks cited

Oral triptan cumulative limit

Class-level cumulative limit

Oral triptan cumulative limit: Maximum of 18 tablets per 30 days across all oral triptan agents.<=18 tablets per 30 days cumulative

Applies across all oral triptan products listed

Example product limit (representative)

Products are covered subject to the listed dispensing limit (quantity per time period) and product designation (brand/generic applicability).

Symbicort (budesonide-formoterol): Dispensing Limit = 3 inhalers per 30 days; designation = BG.3 inhalers/30 days

Representative example from inhaled combination products (Symbicort).

Representative product limits

Representative additional products and their dispensing limits (non-exhaustive in this part).

Breztri Aerosphere (budesonide-glycopyrrolate-formoterol): Dispensing Limit = 1 inhaler per 30 days; designation = B.1 inhaler/30 days

chunk 72

Belbuca (buprenorphine buccal films): Dispensing Limit = 60 films per 30 days; designation = B.60 films/30 days

chunks 72-73

Butrans (buprenorphine transdermal patch): Dispensing Limit = 4 systems per 28 days; designation = BG or B depending on strength.4 systems/28 days

chunks 73-74

Cinryze (C1 esterase inhibitor IV 500 unit): Dispensing Limit = 20 vials per 30 days; designation = B.20 vials/30 days

chunk 75

Berinert (C1 esterase inhibitor IV kit 500 unit): Dispensing Limit = 10 vials per 30 days; designation = B.10 vials/30 days

chunk 75

Haegarda (C1 esterase inhibitor SC 2000/3000 unit): Dispensing Limits = 27 vials per 28 days (2000 unit) and 18 vials per 28 days (3000 unit); designation = B.27 vials/28 days; 18 vials/28 days

chunks 75-76; QL calculation based on CDC 90th percentile weight

Cabometyx/Cabozantinib (oral tablets): Dispensing Limit = commonly 30 tablets per 30 days for many strengths; designation = B.30 tablets/30 days (common)

chunk 77

Clobetasol products (topical corticosteroids): Dispensing Limits include cumulative caps (e.g., 100 g per 30 days or 180 g per 90 days across agents).100 g/30 days or 180 g/90 days cumulative

chunks 89-90

Standard dispensing limits

Products are covered when dispensed at or below the specified per-product quantity limits for the defined time period.

Per-item dispensing limit: Dispensing must not exceed the listed quantity and time window for the specific product (examples include CGM sensors: 3 sensors per 30 days; receivers: 1 per 365 days; coagulation factor IX: 1 mL per 30 days).see item entries

Limits vary by product and formulation

Covered within dispensing limits

Covered when dispensing does not exceed the product-specific limits listed below

General rule

Injectable and pen insulin formulations: Most injectable and pen-injector insulin formulations are limited to 100 mLs per 30 days; limits are cumulative across injectable formulations of the same insulin class.100 mLs per 30 days
chunks 198-204
Combination insulin pens: Xultophy (insulin degludec-liraglutide) = 5 pens per 30 days; Soliqua (insulin glargine-lixisenatide) = 6 pens per 30 days.5 pens/30 days; 6 pens/30 days
chunks 202,205
Insulin infusion kits and reservoirs: Certain starter kits limited to 1 kit per 720 days; reservoirs/pods limited to 30 pods per 30 days.1 kit/720 days; 30 pods/30 days
chunks 207-209
Pen needles and insulin syringes are limited to 300 needles/syringes per 30 days, cumulative across all pen-needle and syringe SKUs.300 per 30 days
chunks 211-217,219-220
Afrezza cartridges: Afrezza inhalation cartridges limited by cartridge strength: e.g., 1260 cartridges per 30 days for certain pack sizes; 2520 cartridges per 30 days for 4-unit cartridges.1260–2520 cartridges per 30 days depending on format
chunks 216,219

Dispensing limits (coverage-with-quantity-criteria)

Coverage limited by specified dispensing quantity limits (QL) and cumulative rules:

General dispensing rules: Dispensing permitted up to the listed quantity limits per product/description and time period. Where stated, QL is cumulative across categories (e.g., all pen needles or all insulin syringes).see product entries

Each product line lists the exact QL and cumulative scope.

Some plans may exclude coverage for particular drug categories or individual agents; the source example calls out categories such as erectile dysfunction agents and notes that state- or plan-specific variations may apply. Coverage limitations are expressed here primarily as per-product dispensing limits (quantity per time period) rather than broad clinical exclusions. Providers and members should verify plan materials or call the member services number on the ID card to confirm whether a listed dispensing limit applies to a given member or whether a specific product is excluded from coverage.

Certain limits operate at the drug-class level as cumulative caps. For example, the oral triptan class is subject to a cumulative maximum of 18 tablets per 30 days across all oral triptan agents; dispensing for any single triptan counts toward that class total.

Some listed products are identified with a brand-only designation in the table; where a product is designated Brand (B) this limits coverage to the brand presentation rather than generic substitution where a generic exists.

Requests that exceed the stated dispensing limits may not be covered. The document indicates that provision of product quantities above the specified dispensing limit without appropriate authorization or clinical justification will be considered outside the listed coverage and may be denied or require additional review or prior authorization.

No additional plan-wide exclusions beyond the stated dispensing limits are listed in these excerpts. Coverage control in this segment is implemented through product-specific quantity and time-period limits rather than by enumerating further drug-class exclusions.

If a prescriber writes for a quantity greater than the dispensing limit, the member may still obtain the medication but will be responsible for the full cost of the portion of the prescription that exceeds coverage. In other words, amounts dispensed beyond the listed limit are the member's financial responsibility unless an exception or prior authorization is granted by the plan.

When a requested dispense would exceed the published quantity limit, the document indicates that prior authorization or clinical justification may be required. For certain high‑cost or limited‑supply products (for example coagulation factors, CGM components, and some biologics), requests above the per-period QL typically trigger a review and may require prior authorization per payer processes before additional quantity is approved.

Prior authorization not specified in this excerpt — coverage is governed by the listed dispensing limits.

Prior Authorization

Specialty Agents and Device Replacement

Certain specialty agents, high‑cost biologics, and durable diabetes devices frequently require prior authorization when requests exceed dispensing limits or for initial coverage. For device replacements (e.g., continuous glucose system receivers, pump starter kits), replacement frequency limits are listed (days/years) and may trigger PA when exceeded.

Prior authorization may be required for specialty agents and high‑cost biologics.
Prior authorization for device replacements — example: continuous glucose system receiver limit = 1 per 365 days; pump starter kits = 1 per 720 days — requests before the interval may need PA.

Denial Risk

Quantity Limits, Claims Adjudication, and Denial Risk

Quantity limits are operational controls: when an approved dispensing limit is exceeded at point of sale or on pharmacy claim adjudication, the claim may be denied or held for review. Pharmacies and prescribers should align prescriptions to the listed billing units and quantities; if an override is needed, document clinical rationale for medical necessity.

Quantity limits imply PA when exceeded — claims exceeding per‑period quantities often trigger review.
Quantity limit exceedance — claims may be denied or require authorization/override.
Exceeding dispensing limits may trigger denial; member may be responsible for full cost if paid out‑of‑pocket.

Documentation Required

Prescription Writing and Documentation

Follow the listed dispensing quantities and refill window rules exactly when writing and submitting prescriptions. For combination or multi‑strength products, ensure cumulative quantity limits across agents or strengths are respected (for example, oral triptans have a cumulative maximum of 18 tablets per 30 days across all agents). Preserve formulation and device packaging information on the claim to match the listed QL.

Adhere to listed dispensing quantities and refill windows (examples: GLP‑1 injectable fill limits: one agent/one strength per 28 days; dulaglutide = 4 pens per 28 days).
Class cumulative limit for oral triptans — maximum 18 tablets per 30 days across all agents.
Formulation and device quantity documentation — prescribe matching NDC/pack size and billing unit to avoid claim issues.
Follow listed dispensing limits — pharmacy claim must conform to listed QL units.

Billing Rule

Billing, Units, and Overrides

Billing unit conventions and packaging counts in this list drive how claims are submitted (e.g., 1 package = 2 mLs = 2 pens, or 1 carton = 2 syringes). When requesting overrides, include supporting documentation of medical necessity and indicate the specific discrepancy (unit, strength, pack size) to facilitate review.

Billing unit documentation — submit claims using the explicit pack/volume conventions.
Formulation and device quantity documentation required for overrides.
Support for overrides — document medical necessity and provide clinical justification when requesting exception to the QL.

Prior Authorization

Quantity‑Based Prior Authorization and Refill Limits

Some dispensing limits are enforced via quantity‑based prior authorization (for example, interferon titration kits limited to 1 kit per 180 days). When a QL is structured as a kit or by cumulative limits across SKUs, expect PA workflows tied to quantity rather than just drug name.

Quantity‑based prior authorization examples — interferon kits and other multi‑unit packs.
Refill/agent limits documentation — GLP‑1 examples: fill limit of one injectable GLP‑1 agent and one strength per 28 days; liraglutide = 3 pens per 30 days (one agent/one strength per 28 days).

Note

Verify Coverage and Member Financial Responsibility

When uncertain about member coverage, the plan may require verification through the member’s ID card or by contacting member services. Members may be responsible for the full cost if they elect to fill quantities beyond the dispensing limits without an approved authorization.

Verify plan‑specific limitations — contact member services or check the back of the member’s ID card.
Member financial responsibility if quantity exceeds limit and no PA/approval is obtained.

ExamplesAbacavir entries show BG; many adalimumab biosimilars show B

inv-92: Cumulative quantity limit definition (oral triptans example)

DefinitionCumulative quantity limit: a single maximum quantity applied across multiple agents in the same therapeutic class (example: oral triptans capped at 18 tablets per 30 days across all agents)

ExampleOral triptans: 18 tablets per 30 DAYS cumulative across all oral triptan agents

ImplicationCumulative limits require aggregation of claims across class when adjudicating quantity limits

inv-93: Dispensing Limit (redundant key term)

TermDispensing Limit: maximum quantity allowed to be dispensed in the specified time period for a listed product

ApplicationMay be expressed in tablets, mLs, pens, syringes, kits, cartridges, grams, or devices per specified days

EnforcementClaims exceeding the dispensing limit may be denied or require prior authorization per plan rules

inv-94: BG / B / G designation explanation

Designation meaningBG = Brand & Generic applicable; B = Brand only; G = Generic only — used to indicate which presentations the dispensing limit applies to

Where shownDisplayed alongside each product entry in the dispensing limits table

EffectBrand-only designation may limit substitution to brand formulation

inv-95: 180/90 cumulative across agents (topical corticosteroids)

Topical steroid cumulative rule180 Grams per 90 DAYS cumulative across listed topical corticosteroid agents (policy lists 100 g/30 days or 180 g/90 days entries)

ExamplesClobetasol propionate ointment/lotion/solution entries reference the cumulative 180/90 cap

ApplicabilityCumulative cap spans multiple agent formulations within topical corticosteroids

inv-96: Receiver/Transmitter/Sensor (CGM components)

CGM componentsReceiver / Transmitter / Sensor are separate components with distinct replacement intervals (Sensor: 2–3 per 28–30 days; Transmitter: 1 per 90 days; Receiver: 1 per 365 days)

Device examplesDexcom g6/g7 sensors and transmitters; Freestyle Libre sensors and readers are listed

Coverage noteDevice prescriptions must match listed formulation and package size

inv-97: billing unit note (example: follitropin cartridge billing)

Billing unit exampleFollitropin beta cartridges: each cartridge billed as 0.420 mL (billing-unit clarification noted in policy)

ImplicationPharmacies must use specified billing units when submitting claims to align with dispensing limits

ReferenceSee follitropin entries in policy for cartridge billing guidance

inv-98: Dispensing Limit expressed as milliliters per 30-day period

mL expressionDispensing limits for many insulin products are expressed as milliliters per 30 DAYS (e.g., 100 mLs per 30 DAYS)

ExamplesMultiple insulin pen and vial entries list 100 mLs per 30 DAYS

Cumulative applicationmL-based limits may be cumulative across injectable formulations of the same insulin

inv-99: Quantity limit cumulative across pen needle SKUs

Cumulative pen-needle QLQuantity limit that is cumulative across all pen needle SKUs — 300 needles per 30 DAYS

Applies to multiple SKUsIncludes 29 g, 31 g, 32 g variants and multiple lengths listed in policy

Enforcement noteClaims exceeding cumulative pen-needle QL may trigger claim edits or denial

inv-100: QL (Dispensing Limit) term explanation

QL term explanationQL (Dispensing Limit) = maximum quantity allowed to be dispensed in the specified time period; may be cumulative across similar items

Time windowsCommon windows: Per 30 DAYS, Per 28 DAYS, Per 90 DAYS, Per 180 DAYS, Per 365 DAYS

Use in adjudicationPharmacy claims must be adjudicated against the product-specific QL and cumulative rules

inv-101: Afrezza cartridges definition and units

Afrezza cartridge unitsAfrezza cartridges are defined by units per cartridge (e.g., 4, 8, 12 unit/cartridge) and limits are specified per cartridge format

Policy examples4-unit cartridges limited to 2520/30 DAYS; 8-unit and 12-unit formats have separate limits (e.g., 1260, 1080) depending on pack size)

Adjudication implicationClaims must be evaluated by cartridge unit format when applying QL

inv-102: Titration pack definition (Rebif example)

Titration pack definitionTitration pack (Rebif): combined pack containing 6 x 8.8 mcg/0.2 mL plus 6 x 22 mcg/0.5 mL = 1 Kit; Dispensing Limit = 1 Kit per 180 DAYS

UsageTitration pack entries indicate combined contents and longer interval kit limits

Related itemsRebif/Rebidose syringes and Avonex kits have separate limits (e.g., 12 syringes/28 days; 1 kit/28 days)

Representative tablet per-30-day limit for this antiretroviral

inv-106: abaloparatide pen 3120 mcg/1.56ml (Tymlos) — 1.56 mLs (1 injection)

Abaloparatide pen quantityAbaloparatide pen 3120 mcg/1.56 mL (Tymlos) — 1.56 mLs (1 injection) per 30 DAYS

Unit equivalencePolicy notes 1.56 mLs equals one injection for the pen presentation

ApplicabilityPen-injector volume limits for single-injection presentations

inv-107: abatacept prefilled syringe (Orencia) — 4 Syringes

Orencia syringe limitAbatacept prefilled syringes (Orencia) — 4 Syringes per 28 DAYS

Presentation variantsMultiple Orencia prefilled syringe strengths listed with same 4-syringe/28-day limit

ImplicationApplies to Orencia auto-injector and prefilled syringe presentations as listed

inv-108: acyclovir buccal tab 50 mg (Sitavig) — 2 Tablets

Sitavig limitAcyclovir buccal tablet 50 mg (Sitavig) — 2 Tablets per 180 DAYS

Formulation noteThis is an example of a short-course or infrequent-use product with a long refill window

DesignationListed as Brand (B) in policy entry

inv-109: adalimumab (various formulations/brands/biosimilars) — commonly 2 Pens or 2 Syringes Per 28 DAYS; starter kits 1 Kit Per 180 DAYS

Adalimumab common limitAdalimumab products (various brands/biosimilars) — commonly limited to 2 Pens or 2 Syringes per 28 DAYS; starter kits often 1 Kit per 180 DAYS

Biosimilar parityMany adalimumab biosimilars are listed with the same 2-per-28-day limit

Product-dependent exceptionsSome starter kits and initiation packs have separate longer interval limits

inv-110: Adalimumab biosimilars — 2 (per period)

Biosimilar exampleAdalimumab biosimilars (multiple brands/strengths) — Dispensing Limit = 2 Pens or 2 Syringes per 28 DAYS

ConsistencyPolicy lists multiple biosimilar entries with identical dispensing limits

Clinical noteLimits apply per product presentation (pen vs syringe) as listed

inv-111: Afatinib (Gilotrif) tablets — 30

Gilotrif limitAfatinib (Gilotrif) tablets — 30 Tablets per 30 DAYS

Applies to strengths30-tablet limit shown for 20/30/40 mg strengths listed

DesignationListed as Brand (B) in policy entry

inv-112: Albuterol inhalers — 2

Albuterol inhaler limitAlbuterol inhalers (HFA/Respiclick/Digihaler/Proventil/Ventolin) — 2 Inhalers per 30 DAYS

Representative productsProAir Respiclick, ProAir Digihaler, Ventolin HFA listed with 2 inhalers/30 days

Multiple presentationsSome combination inhalers have different limits (e.g., 3 Inhalers/30 DAYS for certain combos)

inv-113: Albuterol nebulizer solution — 120

Nebulizer solution exampleAlbuterol nebulizer solution (various strengths) — 120 Vials per 30 DAYS (example entry)

Alternate mL entrySome nebulizer presentations listed as 60 mLs per 30 DAYS or other vial counts depending on concentration

Formulation-specificLimits vary by concentration and presentation as shown in the policy

inv-114: Almotriptan — 18 (class cumulative)

Almotriptan limitAlmotriptan — 18 Tablets per 30 DAYS (class cumulative across oral triptans)

Cumulative ruleCounts toward the 18-tablet class-level triptan cap

FormulationsApplies to listed strengths (6.25 mg, 12.5 mg)