Blue Cross Blue Shield IL Enhanced Dispensing Limits

General Dispensing Limit Rule

Coverage is subject to dispensing limits which apply as specified per product; if a prescriber writes a quantity greater than the dispensing limit, the member may obtain the medication but will be responsible for full cost beyond coverage limits.

Standard dispensing rule: Medication coverage is limited to the specified quantity per prescription or time period listed in the formulary dispensing limits.see product-specific entries

Limits may vary by member plan or state regulations; exceptions not listed here may exist

Prescriber-ordered quantity exceeds limit: If the prescriber-authorized quantity exceeds the listed dispensing limit, the member may still receive the full quantity but will be liable for the portion not covered by the plan.

Enforcement and plan verification: Dispensing limits may be enforced at point-of-sale; verify member-specific plan materials or contact the number on the back of the member ID card to confirm plan limitations or exclusions.

Product-specific Limits

Product-specific dispensing limits (examples present in this section):

Oral formulations (tablets/capsules): Examples include abacavir sulfate solution 960 mLs per 30 days; abacavir sulfate tablets 60 tablets per 30 days; many oral specialty agents have limits of 30, 60, 120 tablets per 30 days as specified per product.product-level as listed

See product list for precise per-product limits

Injectables and biologics: Examples include abatacept subcutaneous prefilled syringe 4 syringes per 28 days; adalimumab auto-injector kits 2 pens per 28 days (starter kits may be limited per 180 days); many biologics have 28-day or kit-based limits.product-level as listed

Quantity limits for biologics may be cumulative across formulations where noted

Insulins and insulin supplies: Common limits include 100 mLs per 30 days for many insulin solutions (e.g., Tresiba, Toujeo, other glargine/detemir products) and 300 units per 30 days for pen needles or insulin syringes; Xultophy limited to 5 pens per 30 days and Soliqua to 6 pens per 30 days.

Coverage of medications is subject to dispensing limits that specify the maximum quantity payable per prescription or within a given time period. These limits may vary by product, benefit plan, and state regulation; some plans may also exclude coverage for specific drug categories (for example, certain erectile dysfunction agents) or restrict mail-service availability. If a prescriber orders a quantity above the listed limit, the member may still obtain the full quantity but will be responsible for the full cost beyond the coverage limit. Verify member-specific plan materials or contact the number on the back of the member ID card for plan-specific exclusions or variations.

This excerpt does not include explicit clinical exclusion criteria (for example, there are no diagnosis‑based or contraindication‑based rules in the provided text). The document provides product‑level dispensing limits and brand/generic designations for many agents (e.g., finerenone, fingolimod, galcanezumab) but does not state clinical conditions under which an agent would be categorically excluded.

Coding, Units, and Common Time Windows

Insulin pens and cartridges - coveredmixedCovered

insulin lispro soln pen-injector (Humalog Pen)	Dispensing Limit = 100 mLs Per 30 DAYS; Generic/Brand = B
insulin lispro soln pen-inj wltransmit port (Humalog Pen)	Dispensing Limit = 100 mLs Per 30 DAYS; Generic/Brand = B
insulin lispro soln pen-injector (Humalog Kwikpen)	Dispensing Limit = 100 mLs Per 30 DAYS; Generic/Brand = B
insulin lispro soln pen-injector (Admelog Solostar)	Dispensing Limit = 100 mLs Per 30 DAYS; Generic/Brand = B
insulin lispro soln pen-injector (Insulin Lispro Kwikpen)	Dispensing Limit = 100 mLs Per 30 DAYS; Generic/Brand = B
insulin lispro-aabc soln pen-inj (Lyumjev Kwikpen)	Dispensing Limit = 100 mLs Per 30 DAYS; Generic/Brand = B
insulin lispro soln cartridge (Humalog)	Dispensing Limit = 100 mLs Per 30 DAYS; Generic/Brand = B

Insulin syringes / needles - coveredmixedCovered

insulin syringe (disp) u-100 ml (Monoject Insulin Syringe/1ml)	Dispensing Limit = 300 Units Per 30 DAYS; QL cumulative for all insulin syringes
insulin syringe (disp) u-100 ml (Monoject Insulin Syringe Regular Luer Tip/Softpack/1ml)	Dispensing Limit = 300 Units Per 30 DAYS; QL cumulative for all insulin syringes
insulin syringelneedle u-100 0.3 ml 29 x 1/2"	Magellan/Monoject variants listed; Dispensing Limit = 300 Units Per 30 DAYS; QL cumulative
insulin syringelneedle u-100 0.3 ml 30 x 5/16"	Magellan/Monoject variants listed; Dispensing Limit = 300 Units Per 30 DAYS; QL cumulative
insulin syringelneedle u-100 0.3 ml 31 x 15/64"	BD Safetyglide/Dropsafe variants; Dispensing Limit = 300 Units Per 30 DAYS; QL cumulative
insulin syringelneedle u-100 1 ml 28 x 1/2"	Monoject/Embecta variants; Dispensing Limit = 300 Units Per 30 DAYS; QL cumulative
insulin syringelneedle u-100 1 ml 29 x 1/2"	Dropsafe/Ulticare/Monoject variants; Dispensing Limit = 300 Units Per 30 DAYS; QL cumulative
insulin syringelneedle u-100 1 ml 30 x 5/16"	Magellan/Monoject variants; Dispensing Limit = 300 Units Per 30 DAYS; QL cumulative
insulin syringelneedle u-100 1 ml 31 x 15/64"	Dropsafe/Aq insulin syringe variants; Dispensing Limit = 300 Units Per 30 DAYS; QL cumulative
insulin syringelneedle u-100 1/2 ml 27 x 1/2"	Insulin Syringes/U-100/0.5ml/27g X 1/2 variant; Dispensing Limit = 300 Units Per 30 DAYS; QL cumulative

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Interferon beta products - coveredmixedCovered

interferon beta- (Betaseron)	Dispensing Limit = 14 Vials Per 28 DAYS; Generic/Brand = B
interferon beta- (Extavia)	Dispensing Limit = 15 Vials Per 30 DAYS; 15 vials/syringes box; Generic/Brand = B
interferon beta-1a auto-inj (Rebif Rebidose)	Dispensing Limit = 12 Syringes Per 28 DAYS; 1 carton = 12 syringes; QL cumulative across strengths
interferon beta-1a im auto-injector kit (Avonex Pen)	Dispensing Limit = 1 Kit Per 28 DAYS; Generic/Brand = B

Selected specialty oral and injectable drugs - coveredmixedCovered

ixazomib citrate cap 2.3 mg (Ninlaro)	Dispensing Limit = 3 Capsules Per 28 DAYS; Generic/Brand = B
ixazomib citrate cap 3 mg (Ninlaro)	Dispensing Limit = 3 Capsules Per 28 DAYS; Generic/Brand = B
ixazomib citrate cap 4 mg (Ninlaro)	Dispensing Limit = 3 Capsules Per 28 DAYS; Generic/Brand = B
ivacaftor tab 150 mg (Kalydeco)	Dispensing Limit = 60 Tablets Per 30 DAYS; Generic/Brand = B
ivacaftor packet 75 mg (Kalydeco)	Dispensing Limit = 60 Packets Per 30 DAYS; Generic/Brand = B
ixekizumab subcutaneous soln auto-injector 80 mg/ml (Taltz)	Dispensing Limit = 1 Syringe Per 28 DAYS; Generic/Brand = B

Misc topical, NSAID, GI, renal binders - coveredmixedCovered

calcipotriene-betamethasone dipropionate oint 0.005-0.064% (Taclonex)	Dispensing Limit = 120 Grams Per 30 DAYS; QL cumulative across agents
fluorouracil cream 5% (Efudex)	Dispensing Limit = 240 Grams Per 180 DAYS; Generic/Brand = BG
fluorouracil cream 0.5% (Carac)	Dispensing Limit = 30 Grams Per 180 DAYS; Generic/Brand = B
ketoprofen cap 25 mg (Ketoprofen)	Dispensing Limit = 360 Capsules Per 30 DAYS; Generic/Brand = B
lanthanum carbonate chew tab (Fosrenol)	Dispensing Limit = per 365 DAYS as specified (360/540/810 depending on strength); Generic/Brand = BG

Common time window — Per 30 DAYS or Per 28/180 DAYS as specified per product

Common time windowPer 30 DAYS or Per 28/180 DAYS as specified per product

Tablets/Capsules per 30 days — common values (30, 60, 74, 90)

Tablets/Capsules per 30 days — common values30, 60, 74, 90

Injectable clotting factor dispensing — 1 mL Per 30 DAYS, dependent on weight/doses

Injectable clotting factor dispensing1 mL Per 30 DAYS, dependent on weight/doses

Example dispensing limits — examples like 30/60/120 Tablets Per 30 DAYS

Example dispensing limitsExamples: 30/60/120 Tablets Per 30 DAYS

Vyleesi (bremelanotide) dispensing limit — 8 doses per 30 days

Vyleesi (bremelanotide)8 doses per 30 days

Brigatinib 30 mg dispensing limit — 120 tablets per 30 days

Brigatinib 30 mg120 tablets per 30 days

C1 esterase inhibitor (Cinryze) dispensing limit — 20 vials per 30 days

C1 esterase inhibitor (Cinryze)20 vials per 30 days

Haegarda dispensing limits — 27 vials/28 days (2000 unit); 18 vials/28 days (3000 unit)

Haegarda dispensing limits27 vials/28 days (2000 unit); 18 vials/28 days (3000 unit)

Xywav (oxybates) dispensing limit — 540 mLs per 30 days

Xywav (oxybates)540 mLs per 30 days

Continuous glucose system receiver limit — Receiver Per 365 DAYS

Continuous glucose system receiverReceiver Per 365 DAYS

Continuous glucose system transmitter limit — Transmitter Per 90 DAYS

Continuous glucose system transmitterTransmitter Per 90 DAYS

Oral triptans monthly cap — Maximum 18 tablets per 30 days across oral triptans

Oral triptans monthly capMaximum 18 tablets per 30 days across oral triptans

Fluorouracil topical limits — 30-240 grams per 180 days depending on formulation

Fluorouracil topical limits30-240 grams per 180 days depending on formulation

Typical dispensing period — Per 30 DAYS

Typical dispensing periodPer 30 DAYS

Per-30-day volume limit — 100 mLs example

Per-30-day volume limit example100 mLs Per 30 DAYS

Combination insulin/GLP-1 pens limits

Xultophy pens per 30 days5 Pens

Soliqua pens per 30 days6 Pens

Pen needle / syringe per 30 days — 300 Units

Pen needle / syringe per 30 days300 Units (QL cumulative across all pen needles)

Insulin syringe dispensing limit — 300 Units Per 30 DAYS

Insulin syringe dispensing limit300 Units Per 30 DAYS (QL cumulative for all insulin syringes)

Interferon vial dispensing limit — 14-15 Vials Per 28-30 DAYS

Interferon vial dispensing limit14-15 Vials Per 28-30 DAYS depending on product

Ixazomib dispensing limit — 3 Capsules Per 28 DAYS

Ixazomib dispensing limit3 Capsules Per 28 DAYS

Example dispensing limit format

Example dispensing limit formate.g., 60 Tablets Per 30 DAYS

Provider Responsibilities and Impact

Prior Authorization

Coverage and Prior Authorization

Coverage and prior authorization rules and dispensing limits vary by plan and state; verify member-specific plan materials or call the number on the back of the member ID card for plan restrictions and exclusions.

Coverage and prior authorization note: Limits and PA requirements may not apply to all members or may vary by state; some agents or categories may be excluded from coverage.
Plan verification required: Confirm member-specific limits, mail-service availability, and exclusions via plan materials or member ID card phone number.

Note

Prior Authorization Not Specified in Excerpt

The excerpt does not consistently list an explicit prior authorization rule for every product. Some product entries list only dispensing quantity and brand/generic designation without a stated PA requirement. When PA is not specified, follow the plan verification step above.

Prior authorization not specified in excerpt for many products — dispensing limits and BG/B/G flags are provided but PA may be absent.
If PA is not listed, verify benefit materials or contact the plan.

Prior Authorization

Dispensing Limits May Trigger Prior Authorization

Dispensing limits in the list may trigger prior authorization or other utilization management controls when a prescriber requests quantities above the listed limit or requests overrides for specialty/limited-distribution products.

Dispensing limits may trigger PA: requests to exceed listed per-period amounts often require prior authorization.
Specialty agents and limited-distribution products commonly require PA to exceed limits.

Billing Rule

Dispensing Limits and Brand/Generic Preference

Many entries include a brand/generic designation (BG, B, G) alongside dispensing limits; these guide substitution, coverage tiering, and cost-sharing. Adhere to the plan’s brand vs generic preference when dispensing or billing.

BG/B/G flags indicate Brand/Generic availability or restriction and may affect coverage and member cost share.
Pharmacies should substitute according to plan rules and document any brand medically necessary requests.

Prior Authorization

Dispensing Limits Imply PA for Overrides

Dispensing limits imply prior authorization or other documentation may be required for overrides. For high-cost biologics, specialty agents, or cumulative limits across strengths/agents, prescribers must supply clinical justification to obtain an override.

Overrides for specialty or high-cost biologics typically require PA and supporting clinical documentation.
Cumulative limits across strengths/agents (e.g., lidocaine patches, insulin formulations) may necessitate documentation to support exceptions.

Billing Rule

Dispensing Quantity Limits

The policy contains detailed per-product dispensing quantity limits (example formats: "2 Pens Per 28 DAYS", "2 Inhalers Per 30 DAYS", "100 mLs Per 30 DAYS"). Providers and pharmacies must adhere to these limits when submitting claims.

Typical QLs shown: pens, syringes, inhalers, tablets, mLs, cartridges, patches — each with a specific per-period limit.
Some entries include package-equivalence notes (e.g., kit = 84 vials = 84 mL).

Denial Risk

Fill-Limit Enforcement

Fill limits are actively enforced for certain classes (example: GLP-1 agents — fill limit of one GLP-1 agent and one strength per 28 days). Expect claim denials when multiple agents/strengths in the same class exceed the class-level fill restriction.

GLP-1 fill restriction: only one GLP-1 agent and one strength per 28 days allowed across listed agents (Trulicity, Byetta, Bydureon, Victoza, etc.).
Class-level limits (e.g., triptans cumulative 18 tablets/30 days) are enforced across agents in the class.

Prior Authorization

Specialty Agent Limits

Specialty agents have specific dispensing limits and fill restrictions; some are limited to a small number of devices/units per period (examples include Repatha, Evolocumab; Tremfya; many biologics). These limits are part of utilization management for high-cost products.

Specialty examples: Repatha (6 pens per 28 days or 2 cartridges/30 days), Tremfya (1 syringe per 28 days), various biologics limited per 28/30/84/90 day windows.
Limited-distribution or specialty-only products may have additional PA or dispensing channel requirements.

Prior Authorization

Prior Authorization for Quantities Above Listed Limits

Prior authorization is typically required to obtain amounts above the listed quantity limits for many products — especially specialty, limited-distribution, or annual/multi-month capped agents. Submit PA with clinical justification when requesting an exceedance.

Per-product PA required for amounts exceeding QLs (e.g., ivacaftor, ixazomib, lenacapavir examples show tight annual or monthly caps).
Annual or multi-month caps (lenacapavir, some gene-therapy–era products) routinely require PA for exceptions.

Prior Authorization

Per-Product Prior Authorization for Amounts Exceeding Quantity Limits

Some products are explicitly noted as requiring per-product prior authorization when amounts exceed quantity limits (examples include ivacaftor, ixazomib, and other specialty oncology or rare-disease agents). Check product-level notes for PA triggers.

Per-product PA may apply for specialty oncology, rare-disease, or highly restricted agents (ivacaftor, ixazomib, lenacapavir).
Check the plan’s PA criteria for required clinical documentation and prior authorization forms.

Prior Authorization

Prior Authorization for Specialty Quantity Exceedance

Prior authorization is required for specialty quantity exceedance in many cases; for example, agents with annual or multi-month limits (lenacapavir, marstacimab) require PA to dispense beyond the stated cap.

Specialty quantity exceedance (annual caps or small annual tablet allotments) usually requires PA and plan review.
Pharmacies should route PA requests to the plan’s specialty pharmacy or PA unit as instructed in plan materials.

Prior Authorization

Utilization-Managed Specialty Drugs

Several specialty drugs in the list are utilization-managed with specific dispensing limits (e.g., mepolizumab, marstacimab, monoclonal antibodies, and coagulation factors). Follow utilization-management pathways for these products.

Utilization-managed specialty drugs often have defined per-period device/unit caps and may require specialty pharmacy channels.
Examples include monoclonal antibodies, coagulation factors, and newer biologic therapies — many require PA and limited dispensing windows.

Billing Rule

Member Cost Liability for Over-Limit Prescriptions

If a prescriber directs dispensing beyond the listed limit and coverage does not permit an override, the member may be responsible for the full cost of the additional medication. Inform members of potential out-of-pocket liability when requesting quantities above plan limits.

Member cost liability for over-limit prescriptions: prescriptions beyond coverage limits may be filled but the member may owe full cost for the excess.
Advise members to confirm benefits prior to authorizing fills beyond listed QLs.

Denial Risk

Dispensing Limit Overages and Denial Risk

Requests that exceed dispensing limits may be denied or subjected to clinical review. Expect denials when claims do not align with listed quantity limits or class-level limits without supporting PA or documentation.

Dispensing limit overages may be denied at point-of-sale or retrospectively upon claim review.
When denied, resubmit with PA and supporting documentation if the plan allows overrides.

Denial Risk

Quantity Limit Exceedance

Claims exceeding quantity limits are at risk of denial. Ensure claims conform to listed per-period amounts and cumulative or class-level limits to avoid claim rejections or retroactive denials.

Quantity limit exceedance may be denied (examples include inhaler QLs, GLP-1 class limits, Vyleesi limits).
Adjust dispensing and billing to match the plan’s stated limits to minimize denials.

Documentation Required

Weight- and Dose-Dependent Limits and Documentation

Certain products require weight- or dose-dependent documentation for appropriate quantity calculation (e.g., coagulation factor products, Sevenfact, C1 esterase inhibitors). Provide patient weight and dosing schedule when submitting PA or claims.

Weight-dependent dosing documentation required: coagulation factors and similar injectable products require weight and dose/date of service documentation.
Examples: C1 esterase inhibitor and coagulation factor VIIa/IX entries note dependence on patient weight and number of doses.

Denial Risk

Quantity-Limit Exceedance May Be Denied Without Documentation

Quantity-limit exceedances without PA or required weight/dose documentation may be denied. For products with dosing tied to weight or number of doses, submit the necessary clinical details with any PA request.

Sevenfact and other factor products: claims lacking weight/dose details or PA may be denied.
Ensure PA submissions include weight, number of doses, and dosing interval when applicable.

Documentation Required

Quantity Calculation Notes

Quantity calculations for some products reference external rationales (for example, CDC 90th percentile adult weight used to set vial limits). Be prepared to provide the calculation basis or patient-specific data when requesting exceptions.

QL calculation notes: some limits are based on CDC 90th percentile weight or other population metrics and rounded operationally.
When requesting overrides, clarify whether the member’s dosing differs from the assumed calculation and provide supporting data.

Billing Rule

Adhere to Dispensing Limits and Required Claim Conformity

Adhere to listed dispensing limits and ensure pharmacy claims conform to the limits (packaging equivalence and cumulative limits apply); nonconforming claims may be denied or require PA.

Adhere to per-product dispensing limits and cumulative limits across formulations/strengths (e.g., insulin mLs, insulin syringe unit caps, lidocaine patch cumulative limits).
Packaging equivalence: some kits/packages have equivalence notes that affect allowable quantities (e.g., 84 vials = 84 mL).

Documentation Required

Dispensing Documentation and Claim Alignment

Document dispensing details and clinical justification when submitting PA or when billing above limits. Required documentation may include weight, dose schedule, rationale for brand medically necessary requests, and prior authorization forms.

Dispensing documentation note: include clinical notes, weight/dose calculations, and PA forms as required by the plan.
Align claims with dispensing limits and include supporting documentation for any requested exceedance.

Billing Rule

Cumulative Quantity Note

Cumulative quantity limits apply across strengths and formulations for some products (examples include lidocaine patches, insulin formulations, topical corticosteroids). When calculating allowable quantities, sum across all applicable strengths and formulations.

Cumulative QL examples: azithromycin 600 mg cumulative across strengths; clobetasol 180/90 cumulative across agents; insulin mL limits cumulative across formulations.
Pharmacies must sum quantities across strengths/formulations to determine whether a claim exceeds the cumulative limit.

Step Therapy

Class-Level Limits and GLP-1 Step/Fill Restriction

Class-level limits are enforced for certain medication classes (examples: GLP-1 agents — one agent & one strength per 28 days; triptans cumulative 18 tablets per 30 days). Ensure prescriptions respect class-level limits and be prepared to select therapeutic interchange where allowed.

GLP-1 step/fill restriction: one GLP-1 agent and one strength per 28 days across listed GLP-1 products (Trulicity, Exenatide, Victoza, etc.).
Class-level limits (e.g., oral triptans) are cumulative across all agents in the class and will be enforced.

Product-Level Quantity Limits (Alphabetical Selection)

abacavir sulfate soln 20 mg/mL (Ziagen)

abacavir sulfate soln 20 mg/mL (Ziagen)960 mLs Per 30 DAYS

Formulary noteListed with Brand/Generic designation BG in entry

Apply per productVolume limit expressed as Per 30 DAYS per product entry

abacavir sulfate tab 300 mg (Ziagen)

abacavir sulfate tab 300 mg (Ziagen)60 Tablets Per 30 DAYS

Brand/GenericEntry listed with BG designation

Per‑product specificityFollow the specific tablet limit for this strength

abatacept subcutaneous prefilled syringe (Orencia)

abatacept subcutaneous prefilled syringe (Orencia)4 Syringes Per 28 DAYS

Packaging note1.6 mLs = 4 syringes per box as listed

Brand statusListed as Brand (B)

adalimumab auto-injector kit / prefilled syringe (various)

adalimumab auto-injector kit / prefilled syringe2 Pens or 2 Syringes Per 28 DAYS (kits may use Kit Per 180 DAYS)

Multiple biosimilarsMany adalimumab branded and biosimilar products listed with identical 2 Pens/2 Syringes Per 28 DAYS limits

Starter kit exceptionSome adalimumab starter kits limited Kit Per 180 DAYS

abaloparatide (Tymlos) pen

abaloparatide (Tymlos) pen1.56 mLs Per 30 DAYS

Unit equivalence1.56 mLs corresponds to the injection pen fill noted in listing

Brand statusListed as Brand (B)

adalimumab-atto auto-injector (Amjevita)

adalimumab-atto auto-injector (Amjevita)2 Pens or 2 Syringes Per 28 DAYS

Multiple presentationsAmjevita listed in multiple strengths/presentations with same 2 Per 28 DAYS limit

Brand statusListed as Brand (B)

albuterol sulfate inhaler (various)

albuterol sulfate inhaler (HFA/Respiclick/Digihaler)2 Inhalers Per 30 DAYS

Nebulizer solution exampleAlbuterol nebulizer solution 0.083% limited to 375 mLs Per 30 DAYS

Packaging/90-day noteSome inhalers limited to 6 packages per 90 days as additional constraint

albuterol nebulizer solution 0.083%

albuterol nebulizer solution 0.083%375 mLs Per 30 DAYS

Alternative nebulizer limitsOther nebulizer presentations listed at 120 Vials Per 30 DAYS or 375 mLs depending on product

Brand statusListed as Generic (G) or BG per entry

alpelisib oral granules packet 50 mg (Vijoice)

alpelisib oral granules packet 50 mg (Vijoice)28 Packets Per 28 DAYS

Pack-based limitsAlpelisib therapy packs also have 56 Tablets Per 28 DAYS for certain pack dosing

Brand statusListed as Brand (B)

amifampridine phosphate 10 mg (Firdapse)

amifampridine phosphate 10 mg (Firdapse)300 Tablets Per 30 DAYS

High tablet QLListed as 300 Tablets Per 30 DAYS for Firdapse

Brand statusListed as Brand (B)

Various — common QLs

Common QLs seen across entriesTypical quantity limits include 30, 60, 90, 120, or 1 mL depending on drug/formulation

Tablet/capsule examplesMany oral agents use 30–120 Tablets Per 30 DAYS limits

Injectable 1 mL exampleHemophilia and factor products commonly limited to 1 mL Per 30 DAYS

Various common QLs (examples)

Common tablet/pens examplesExamples across entries include 30, 60, 90, 120 Tablets and 1 mL for injectables

GLP‑1 pen fill ruleDulaglutide and other GLP‑1 pens use Pens Per 28 DAYS with a fill‑limit of one agent/strength per 28 days

Apply product‑specific limitsUse the exact per‑product entry when conflicting default examples occur

asciminib hcl tab 100 mg (Scemblix)

asciminib 100 mg (Scemblix)120 Tablets Per 30 DAYS

Other strengthsAsciminib 20 mg listed at 60 Tablets Per 30 DAYS; 40 mg listed at 240 Tablets in other entries

Brand statusListed as Brand (B)

asenapine maleate SL tab 10 mg (Saphris)

asenapine SL tab 10 mg (Saphris)60 Tablets Per 30 DAYS

Other formulationsTransdermal patches (Secuado) have separate patch limits (30 Patches Per 30 DAYS)

Brand/genericEntries list BG/B as appropriate

atazanavir sulfate cap 200 mg (Reyataz)

atazanavir sulfate cap 200 mg (Reyataz)60 Capsules Per 30 DAYS

Other strengthsSome atazanavir strengths listed at 30 Capsules Per 30 DAYS or packet limits

Packaging noteOral powder packets listed with packet-to-box equivalence (30 packets = 1 box)

atogepant (Qulipta) examples

atogepant (Qulipta) examples30 Tablets Per 30 DAYS

Multiple strengths10/30/60 mg strengths each listed with 30 Tablets Per 30 DAYS in examples

Brand statusListed as Brand (B)

atomoxetine caps (various strengths)

atomoxetine caps (various strengths)30–60 Capsules Per 30 DAYS depending on strength

Strength-based limitsHigher strengths may have lower QL (e.g., 30 Capsules) vs lower strengths 60 Capsules

Brand/genericEntries list BG or B as applicable

avacopan cap 10 mg (Tavneos)

avacopan cap 10 mg (Tavneos)180 Capsules Per 30 DAYS

High capsule QLLarge QL reflects chronic specialty dosing for some agents

Brand statusListed as Brand (B)

azacitidine tab 200/300 mg (Onureg)

azacitidine tab 200/300 mg (Onureg)14 Tablets Per 28 DAYS

Pack/28-day dosingOnureg entries use 28‑day supply windows for tablet dosing

Brand statusListed as Brand (B)

azithromycin tab 250/500/600 mg

azithromycin tab 250/500/600 mg60 Tablets Per 180 DAYS (quantity cumulative across strengths)

Cumulative strength ruleQuantity limit is cumulative across strengths per entry

Multiple dosing windowsUses a 180‑day window for some macrolide entries

aztreonam lysine for inhalation (Cayston)

aztreonam lysine for inhalation (Cayston)84 mLs Per 56 DAYS

Kit equivalenceKit = 84 vials = 84 mL as noted

Brand statusListed as Brand (B)

belimumab subcutaneous solution (Benlysta)

belimumab subcutaneous solution (Benlysta)4 Syringes Per 28 DAYS

Presentation typesListed for auto‑injector and prefilled syringe presentations

Brand statusListed as Brand (B)

bimekizumab (Bimzelx)

bimekizumab (Bimzelx)2 Pens Per 56 DAYS (some presentations use 2 Pens or 1 Pen Per 28 DAYS)

Presentation-specificLimits differ by concentration/presentation as listed (160 mg/320 mg)

Brand statusListed as Brand (B)

bremelanotide (Vyleesi)

bremelanotide (Vyleesi)8 Pens/Doses Per 30 DAYS

Quantity noteQuantity limit allows for 8 doses per 30 days as explicitly stated

Brand statusListed as Brand (B)

brexpiprazole (Rexulti) formulations

brexpiprazole (Rexulti)30 Tablets Per 30 DAYS

Multiple strengthsAll listed strengths limited to 30 Tablets Per 30 DAYS

Brand statusListed as Brand (B)

brigatinib 30 mg

brigatinib 30 mg120 Tablets Per 30 DAYS

Other strengthsBrigatinib 90/180 mg have different per‑30‑day limits as listed

Brand/genericEntries indicate BG/B as applicable

butalbital-acetaminophen 50/300 mg

butalbital-acetaminophen 50/300 mg180 Tablets Per 30 DAYS

High QL exampleUsed as an example of higher tablet limits for certain analgesics

FormulationApplies to listed combination product strengths

Cinryze 500 unit

Cinryze 500 unit20 Vials Per 30 DAYS

Berinert 500 unit10 Vials Per 30 DAYS

Haegarda examplesHaegarda 2000 unit = 27 Vials Per 28 DAYS; Haegarda 3000 unit = 18 Vials Per 28 DAYS

Berinert 500 unit

Berinert 500 unit10 Vials Per 30 DAYS

Calculation rationaleLimit example references CDC 90th percentile weight averaging used in rationale

Brand statusListed as Brand (B)

Haegarda (2000 unit)

Haegarda (2000 unit)27 Vials Per 28 DAYS

Haegarda (3000 unit)18 Vials Per 28 DAYS

Calculation noteQL based on CDC 90th percentile weight and rounding to nearest even dose

Haegarda (3000 unit)

Haegarda (3000 unit)18 Vials Per 28 DAYS

Calculation rationaleCDC 90th percentile weight used to derive vial counts

Brand statusListed as Brand (B)

Xywav (sodium oxybates)

Xywav (sodium oxybates)540 mLs Per 30 DAYS

Formulation detailCalcium/magnesium/potassium/sodium oxybates oral solution 500 mg/mL listed with 540 mLs Per 30 DAYS

Brand statusListed as Brand (B)

cenegermin (Oxervate)

cenegermin (Oxervate)56 Vials Per 56 DAYS

Ophthalmic vial packsListed with a 56‑day window for vial supply

Brand statusListed as Brand (B)

cladribine (Mavenclad) therapy packs

cladribine (Mavenclad) therapy packsVarious per 301 DAYS (e.g., 20, 8, 10, 12, 14, 8, 9 tablets depending on pack)

Long windowTherapy packs limits expressed over a 301‑day period per pack type

Pack-specificDifferent pack sizes have distinct tablet counts and limits

clobetasol prop lotion 0.05%

clobetasol prop lotion 0.05%177 mLs Per 90 DAYS

clobetasol prop oint 0.05%180 Grams Per 90 DAYS

Cumulative noteEntries note 180/90 cumulative across agents

clobetasol prop oint 0.05%

clobetasol prop oint 0.05%180 Grams Per 90 DAYS

Cumulative across agentsLimit shown as cumulative across similar agents in 90‑day window

Formulation specificsOintment/solution/spray entries have similar cumulative limits

clozapine suspension (Versacloz) 50 mg/mL

clozapine suspension (Versacloz) 50 mg/mL540 mLs Per 30 DAYS

Oral formulationsOrally disintegrating tablet strengths listed with 90–180 Tablets Per 30 DAYS depending on strength

Brand statusVersacloz listed as Brand (B)

coagulation factor IX (various strengths)

coagulation factor IX (various strengths)1 mL Per 30 DAYS

Applies across strengthsMultiple recombinant and human factor IX products listed with 1 mL Per 30 DAYS

Brand designationEntries list Brand (B) for many products

coagulation factor VIIa (Sevenfact) various strengths

coagulation factor VIIa (Sevenfact)1 mL Per 30 DAYS (dependent on patient weight and number of doses)

Weight/dose dependencyLimits explicitly note dependence on patient weight and dosing

Coverage implicationClaims exceeding weight‑based limits may be denied without documentation

continuous blood glucose system sensors

continuous blood glucose system sensors3 Sensors Per 30 DAYS (Dexcom g6/g7, Freestyle Libre 3) or 2 Sensors Per 28 DAYS for some Libre models

Model-specific limitsDexcom sensors: 3 Per 30 DAYS; Freestyle Libre 14‑day models: 2 Per 28 DAYS

Receiver/transmitter separateReceiver Per 365 DAYS; Transmitter Per 90 DAYS

continuous blood glucose system sensors (Freestyle Libre variants)

continuous blood glucose system sensors (Libre variants)2 Sensors Per 28 DAYS for Freestyle Libre 14‑day / Zl / 3 models

Alternate 30‑day listingSome Libre Plus/3 Plus models listed at 2 Sensors Per 30 DAYS

Cumulative device rulesSensors, transmitters, and receivers have separate period limits

continuous glucose system receiver

continuous glucose system receiverReceiver Per 365 DAYS

ExamplesDexcom g6/g7 and Freestyle Libre receivers listed with annual receiver replacement

Claim handlingReceiver quantity limited annually regardless of sensor/transmitter fills

continuous glucose system transmitter (Dexcom g6)

continuous glucose system transmitter (Dexcom g6)Transmitter Per 90 DAYS

Device replacement frequencyTransmitter replacements limited to one per 90‑day interval

Separate from sensors/receiverTransmitter limit independent of sensor and receiver limits

cyclosporine ophthalmic emulsion (Klarity-C / Restasis)

cyclosporine ophthalmic emulsion (Klarity‑C / Restasis)60 Vials Per 30 DAYS

Multiple presentationsSome formulations listed as Bottle Per 30 DAYS or 120 Vials Per 30 DAYS for specific brands

Brand statusEntries list BG/B designations per product

dabigatran capsules 150 mg

dabigatran capsules 150 mg60 Capsules Per 30 DAYS

Packet/pack limitsSome pellet/packet packs have 120 Packets Per 30 DAYS depending on formulation

Brand/genericListed as BG/B as appropriate

daridorexant (Quviviq) 25/50 mg

daridorexant (Quviviq) 25/50 mg30 Tablets Per 30 DAYS

Class cumulativeSome sedative‑hypnotic entries note QL cumulative across agents

Brand statusListed as Brand (B)

decitabine-cedazuridine (Inqovi) 35-100 mg

decitabine‑cedazuridine (Inqovi) 35–100 mg5 Tablets Per 28 DAYS

Short 28‑day windowOral oncology agents often use 28‑day packs/limits

Brand statusListed as Brand (B)

deferasirox tab 90 mg (Jadenu)

deferasirox tab 90 mg (Jadenu)30 Tablets Per 30 DAYS

Other deferasirox entriesMultiple deferasirox formulations listed with 30–90 Tablets Per 30 DAYS depending on strength

Brand/genericEntries list BG/B designations

deferasirox 125 mg (Exjade)

deferasirox 125 mg (Exjade)30 Tablets Per 30 DAYS

Multiple Exjade strengthsOther Exjade strengths similarly limited to 30–90 Tablets Per 30 DAYS

Formulation noteSome granular/suspension forms have separate mL limits

deferasirox 250 mg (Exjade)

deferasirox 250 mg (Exjade)30 Tablets Per 30 DAYS

Consistency across strengthsMany strengths share the 30 Tablets Per 30 DAYS limit unless otherwise noted

Brand statusListed as BG/B per entry

deferasirox 500 mg (Exjade)

deferasirox 500 mg (Exjade)90 Tablets Per 30 DAYS

Higher-dose strength500 mg strength lists a higher tablet QL (90 per 30 days)

Brand/genericEntry lists BG designation

deferiprone twice daily 1000 mg (Ferriprox)

deferiprone 1000 mg (Ferriprox) twice daily270 Tablets Per 30 DAYS

Oral solution alternativeDeferiprone oral solution listed with 2700 mLs Per 30 DAYS

Brand statusEntries list B or BG as applicable

Requirement	Details
Fill limit for GLP-1 agents
One GLP-1 agent and one strength per 28 days
Applies to listed GLP-1 agents (example: dulaglutide [Trulicity] 0.75 mg and 1.5 mg pens)

Requirement	Details
Fill limit for GLP-1 agents
One GLP-1 agent and one strength per 28 days
Applies to listed GLP-1 agents (example: exenatide and other GLP-1 formulations)

OpenPayer

Enhanced Drug Dispensing Limits

Coverage and Dispensing Limits

Coding, Units, and Common Time Windows

Provider Responsibilities and Impact

Product-Level Quantity Limits (Alphabetical Selection)

Definitions and Designations

Step Therapy and Fill Restrictions

Background and Rationale