CurrentBlue Cross Blue Shield - IllinoisPolicy N/A

Basic Dispensing Limits (DL)

Lists quantity and time-based dispensing limits for covered medications; limits may vary by plan or state and members may pay full cost for quantities beyond coverage.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyBasic Dispensing Limits (DL)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionIf a prescription exceeds dispensing limits the member may obtain the medication but is responsible for the full cost beyond coverage; verify plan-specific limits via the number on the ID card.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30-day supply commonmany drugs limited per 30 DAYS

2 Pens Per 28 DAYScommon adalimumab limit

2 Pens / 4 Syringesexamples include

BG/B/Gbrand/generic flags present

Dispensing Limits and Per-Product Rules

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Limits are specified per product as maximum quantity per defined time period (e.g., Tablets Per 30 DAYS; Pens Per 28 DAYS).

Dispensing limits shown may vary by plan or state and may not apply to all members; verify plan-specific limits via member ID card or plan materials.

If a prescription exceeds the dispensing limit the member may still obtain the medication but is responsible for the full cost beyond coverage.

Selected dispensing limit entries

Selected adalimumab product examples with their per-product dispensing rules:

Adalimumab (Amjevita) prefilled syringe 20 mg/0.2 mL — Dispensing Limit = 2 Syringes Per 28 DAYS; designation = B.

Adalimumab (Hadlima) auto-injector 40 mg/0.8 mL — Dispensing Limit = 2 Pens Per 28 DAYS; designation = B.

Adalimumab (Simlandi) auto-injector kit 80 mg/0.8 mL — Dispensing Limit = 2 Pens Per 28 DAYS; designation = B.

Inhaler, nebulizer, and triptan limits

Examples for inhaler, nebulizer, and oral triptan limits (including cumulative rules):

Albuterol inhalers (e.g., Proair Respiclick, Ventolin HFA) — Dispensing Limit = 2 Inhalers Per 30 DAYS (some entries note 6 packages per 90 days); designation = BG.

Albuterol nebulizer solutions — examples include 60 mLs Per 30 DAYS, 375 mLs Per 30 DAYS; some entries note QL cumulative across strengths.

Oral triptans (e.g., almotriptan, eletriptan) — Dispensing Limit = 18 Tablets Per 30 DAYS; the quantity limit is cumulative across all oral triptan agents.

Product dispensing limit examples

Examples of per-product dispensing limits from stimulant, injectable, and specialty product segments:

Dyanavel XR (amphetamine XR) — Dispensing Limit = 30 Tablets Per 30 DAYS; designation = B.

Adzenys XR-ODT formulations — Dispensing Limit = 60 or 30 Tablets Per 30 DAYS depending on strength; designation = B.

Mydayis (amphetamine-dextroamphetamine ER) — Dispensing Limit = 30 Capsules Per 30 DAYS; designation = BG.

Anakinra 100 mg/0.67 mL (Kineret) — Dispensing Limit = 28 Syringes Per 28 DAYS; designation = B.

Coagulation factor products — Dispensing Limit expressed as mL Per 30 DAYS and is dependent on patient weight and number of doses.

Product-specific dispensing limits

Per-product dispensing rules and notable cumulative notes:

Aripiprazole starter/kit entries (Abilify Mycite Starter Kit) — Dispensing Limit = 30 Tablets Per 30 DAYS; designation noted per entry.

Asciminib (Scemblix) 100 mg — Dispensing Limit = 120 Tablets Per 30 DAYS; designation = B.

Azithromycin (Zithromax Z-Pak) — Dispensing Limit = 60 Tablets Per 180 DAYS; note: quantity limits are cumulative across strengths.

Aztreonam lysine for inhalation (Cayston) — Dispensing Limit = 84 mLs Per 56 DAYS.

Selected dispensing limit entries (excerpt)

Excerpt of selected per-product dispensing limits with brand/generic applicability:

Brigatinib tab 180 mg (Alunbrig) — Dispensing Limit = 30 Tablets Per 30 DAYS; designation = BG.

Brigatinib initiation therapy pack 90 mg & 180 mg — Dispensing Limit = 30 Tablets Per 180 DAYS; designation = B.

Brimonidine tartrate ophthalmic solution 0.15% (Alphagan P) — Dispensing Limit = 5 mLs Per 20 DAYS; designation = BG.

Budesonide inhalation suspensions — examples include 120 mLs Per 30 DAYS (Pulmicort) and 240 mLs Per 30 DAYS for some strengths; inhaler entries mapped to blisters/doses.

Per-product dispensing limit entries

Per-product dispensing limit examples including device and specialty items:

Clozapine ODT and tablet strengths — Dispensing Limits vary (examples: 90, 180, 270 Tablets Per 30 DAYS) with designation noted per strength.

Coagulation factor VIIa (Sevenfact) — Dispensing Limit = 1 mL Per 30 DAYS (weight- and dose-dependent).

Continuous glucose system sensors (Dexcom, FreeStyle Libre) — Dispensing Limits example: 3 Sensors Per 30 DAYS; receivers and transmitters have longer intervals (Receiver Per 365 DAYS; Transmitter Per 90 DAYS).

Product dispensing limit items

Per-product dispensing quantity rules (name, strength/form, limit, BG/B/G):

Deferasirox (Jadenu/Exjade) formulations — common Dispensing Limit = 30 or 90 Tablets Per 30 DAYS depending on formulation; designation = BG.

Deferiprone (Ferriprox) — examples: 270 Tablets Per 30 DAYS or large mL suspension limits; designation varies by line.

Desoximetasone topical agents — Dispensing Limit = 100 Grams Per 30 DAYS with 100/30 cumulative across agents; designation = BG.

Deutetrabenazine (Austedo) — Dispensing Limits examples: 120 or 60 Tablets Per 30 DAYS depending on strength; designation = B.

Per-product dispensing limits (excerpt)

Excerpt of per-product dispensing limits and formulary designations (quantity per time period and BG/B/G flags):

Droxidopa (Northera) — Dispensing Limits examples: 450 Capsules Per 30 DAYS (100 mg) and 180 Capsules Per 30 DAYS (200/300 mg); designation = BG.

Dulaglutide (Trulicity) auto-injectors — Dispensing Limit = Pens Per 28 DAYS; designation = B.

Dupilumab (Dupixent) — 200 mg auto-injector: 2 Pens Per 28 DAYS (2.28 mLs); 300 mg prefilled syringe: 4 Syringes Per 28 DAYS (carton =2 syringes =4 mLs); designation = B.

Edaravone oral suspension (Radicava ors) — Starter kit: 70 mLs Per 180 DAYS; maintenance: 50 mLs Per 28 DAYS; starter kits set up at NDC.

Emtricitabine solutions — examples: 680-720 mLs Per 28-30 DAYS depending on entry; designation = B.

Encorafenib (Braftovi) — Dispensing Limit = 180 Capsules Per 30 DAYS; designation = B.

Sample product criteria

Sample product entries showing max quantity per time period and brand/generic designation:

Enasidenib (Idhifa) 100 mg — Dispensing Limit = 30 Tablets Per 30 DAYS; designation = B.

Encorafenib (Braftovi) 75 mg — Dispensing Limit = 180 Capsules Per 30 DAYS; designation = B.

Evolocumab (Repatha) auto-injector — Dispensing Limit = Pens Per 28 DAYS; designation = B.

Ferric citrate (Auryxia) — Dispensing Limit = 1080 Tablets Per 365 DAYS; designation = B.

Sample dispensing limit criteria

Additional sample dispensing limit criteria with cumulative topical notes:

Fingolimod lauryl sulfate (Tascenso Odt) — Dispensing Limit = 30 Tablets Per 30 DAYS; designation = B.

Fluocinonide topical agents — examples: 90 Grams Per 30 DAYS or 120 Grams Per 90 DAYS; many entries note a 100/30 cumulative limit across agents.

Fluorouracil creams — examples: 30-240 Grams Per 180 DAYS depending on formulation; designation varies by product.

Sample dispensing rules

Sample dispensing rules and notes on cumulative rules for injectables and topicals:

Gentamicin sulfate cream/ointment 0.1% — Dispensing Limit = 120 Grams Per 90 DAYS; designation = G.

Glatiramer acetate (Copaxone) — examples: 30 Syringes Per 30 DAYS (1 kit = 30 syringes) or 12 Syringes Per 28 DAYS depending on presentation; designation = BG.

Halcinonide and halobetasol topical agents — example limits include 90 Grams Per 30 DAYS with 100/30 cumulative across agents, or 150-180 Grams Per 90 DAYS with cumulative rules.

Insulin glargine and other injectable insulins — Dispensing Limit = 100 mLs Per 30 DAYS; note: quantity limits are cumulative across injectable formulations.

per-product dispensing limits

Per-product dispensing quantities and cumulative rules for insulin products and devices:

Many injectable insulins (e.g., insulin glargine, degludec, lispro) — Dispensing Limit = 100 mLs Per 30 DAYS; quantity limits are cumulative across injectable formulations.

Soliqua 100/33 (insulin glargine-lixisenatide) — Dispensing Limit = 6 Pens Per 30 DAYS (18 mLs).

Insulin pen needles — Dispensing Limit = 300 Units Per 30 DAYS; QL cumulative across all pen needles.

Afrezza inhalation cartridges — Dispensing Limit examples vary by SKU (e.g., 1260, 1080, 1800, 2520, 900 cartridges Per 30 DAYS).

Interferon beta products

Interferon beta product kit/carton and syringe limits:

Rebif Titration Pack — Dispensing Limit = Kit Per 180 DAYS; designation = B.

Rebif Rebidose/other Rebif syringes — Dispensing Limit = 12 Syringes Per 28 DAYS (1 carton = 12 syringes); QL cumulative across strengths; designation = B.

Betaseron and Extavia examples noted with per-vial or per-day limits as listed in the document.

Miscellaneous formulations

Selected oral and topical formulation examples with per-period gram/mL/capsule limits:

Ipratropium bromide inhalation (Atrovent HFA) — Dispensing Limit = 2 Inhalers Per 30 DAYS; designation = B.

Ivacaftor packets (Kalydeco) — Dispensing Limit = 60 Packets Per 30 DAYS; designation = B.

Ivermectin cream 1% (Soolantra) — Dispensing Limit = 45 Grams Per 30 DAYS; designation = BG.

Lanthanum carbonate

Lanthanum carbonate annual dispensing limits:

Lanthanum carbonate chewable tablets 1000 mg — Dispensing Limit = 360 Tablets Per 365 DAYS; designation = BG.

Lanthanum carbonate chewable tablets 500 mg — Dispensing Limit = 810 Tablets Per 365 DAYS; designation = BG.

Lanthanum carbonate oral powder packs — Dispensing Limit = 360 or 540 Packs Per 365 DAYS depending on strength; designation = B for some pack strengths.

Selected dispensing limit criteria

Selected dispensing limit criteria (various product examples):

Lansoprazole 30 mg (Prevacid Solutab) — Dispensing Limit = 60 Tablets Per 30 DAYS; designation = BG.

Lasmiditan succinate 100 mg (Reyvow) — Dispensing Limit = 8 Tablets Per 30 DAYS; designation = B.

Letermovir (Prevymis) — Dispensing Limit = 200 Tablets Per 365 DAYS; note: quantity limit is cumulative at GPI 12; designation = B.

Lenacapavir (Sunlenca) — Dispensing Limit = 4 Tablets Per 365 DAYS; designation = B.

Topical product cumulative limits

Cumulative quantity notes for topical and lidocaine products:

Lidocaine topical formulations (creams, gels, lotions, patches, powders) — many entries show Dispensing Limit = 120 Each Per 30 DAYS with the quantity limit cumulative across formulations.

Lidocaine-prilocaine cream 2.5-2.5% — Dispensing Limit = 60 Grams Per 30 DAYS; designation = G.

Lidocaine-tetracaine topical (Synera/Pliaglis) — Dispensing Limits specified per product with per-28- or per-30-day intervals; cumulative rules apply across related formulations.

Sample product limits

Sample product limits showing dispensing quantity and BG/B/G status:

Lifitegrast ophthalmic solution 5% (Xiidra) — Dispensing Limit = 60 Vials Per 30 DAYS; designation = B.

Linaclotide (Linzess) — Dispensing Limit = 30 Capsules Per 30 DAYS; designation = B.

Linezolid oral suspension — Dispensing Limit = 600 mLs Per 180 DAYS; designation = BG.

Liraglutide (Saxenda) — Dispensing Limit = 15 mLs Per 30 DAYS; designation = B.

Codes, Examples, and Unit Examples

Drug-specific dispensing entriesNDC

Lists drug-specific dispensing limits (drug name, strength, dispensing limit and interval) but no billing/CPT/HCPCS codes in this chunk

Adalimumab productsNDC

Multiple branded and generic adalimumab products with specified per-28-day dispensing limits (e.g., 2 Pens Per 28 DAYS; 2 Syringes Per 28 DAYS)

Albuterol productsNDC

Albuterol inhaler and nebulizer formulations with per-30-day limits and cumulative QL notes (e.g., 2 Inhalers Per 30 DAYS; 375 mLs Per 30 DAYS)

Product dispensing rules (no procedure codes)mixed

No procedure or billing codes present in these document segments; entries are drug product / quantity rules

Brand/Generic status indicatormixed

BG/B/G

Brand and Generic availability indicator (BG = Generic and Brand; B = Brand Only; G = Generic only)

Brand/generic availability codesmixed

No codes listed

Codes not present / no standard billing codesmixed

No CPT/HCPCS/ICD-10/NDC codes provided in these excerpts; only product names, unit quantities, and brand/generic flags are listed

Product-level dispensing limits (N/A for procedure codes)mixed

No codes listed

NDC / packaging notesmixed

No codes listed

Dispensing limits (no CPT/HCPCS/ICD codes in this excerpt)mixed

Per-product dispensing limit entries (no procedure or billing codes provided in this section)

Product dispensing examplesNDC

Examples of product-level dispensing limits (e.g., glecaprevir-pibrentasvir = 150 Packets Per 30 DAYS; 90 Tablets Per 30 DAYS)

Drug entries (product-level)NDC

Product-level dispensing limits and brand/generic designation (BG/B/G) provided; no standardized billing codes listed

Codes absent / product descriptions onlymixed

No CPT/HCPCS/ICD codes listed; product identifiers are drug/device descriptions (no standardized codes provided)

InhalersmixedCovered

Ipratropium bromide HFA (Atrovent HFA): 2 Inhalers Per 30 DAYS; Combivent Respimat: 2 Inhalers Per 30 DAYS

Oncology oral agent limitsmixedCovered

Ixazomib (Ninlaro): 3 Capsules Per 28 DAYS

Drug-level entries (no procedure/diagnosis codes)mixed

Lanthanum carbonate and other drug-level entries list annual or per-period dispensing limits; no procedure/diagnosis codes present

NDC-level / product listingNDC

Product names with quantity/time limits and BG/B/G flags (e.g., lifitegrast 60 Vials Per 30 DAYS; linaclotide 30 Capsules Per 30 DAYS)

Examples and Key Values

Example dispensing thresholds

Example tablet/volume/pen thresholds60 Tablets Per 30 DAYS; 2 Pens Per 28 DAYS; 1.56 mLs Per 30 DAYS

Large-volume liquid example960 mLs Per 30 DAYS (abacavir solution)

Starter pack examplePack Per 180 DAYS (apixaban starter pack)

Oral triptans cumulative limit

Oral triptan cumulative capMaximum 18 Tablets Per 30 DAYS across all oral triptan agents

Example agent entryAlmotriptan 12.5 mg = 18 Tablets Per 30 DAYS

Additional triptan exampleFrovatriptan 2.5 mg = 18 Tablets Per 30 DAYS

Standard tablet limit

Standard tablet monthly limit30 Tablets Per 30 DAYS (common for many oral agents)

Alternate common limit60 Tablets Per 30 DAYS (used for several agents)

Example product with 30/30Afatinib 20/30/40 mg = 30 Tablets Per 30 DAYS

Apixaban dispensing threshold (example)

Apixaban 5 mg74 Tablets Per 30 DAYS

Apixaban starter packPack Per 180 DAYS

Apixaban 2.5 mg noteListed with brand/generic designation

Dispensing limit examples (unit / period combos)

Common unit/period combos30 Tablets Per 30 DAYS; 60 Tablets Per 30 DAYS; 240 Packets Per 30 DAYS; 84 mLs Per 56 DAYS

Inhaler example2 Inhalers Per 30 DAYS (albuterol/Proair)

High-capacity capsule example240 Capsules Per 30 DAYS (alectinib example)

Example dispensing limits (per-entry)

Per-entry quantity/period examples30 Tablets Per 30 DAYS; 2 Inhalers Per 30 DAYS; 120 mLs Per 30 DAYS

Capsule pack example56 Packets Per 28 DAYS (ledipasvir-sofosbuvir)

28-day capsule example56 Capsules Per 28 DAYS (duvelisib)

Dispensing period examples

Common dispensing periodsPer 30 DAYS (most common); Per 28 DAYS; Per 365 DAYS; Per 90 DAYS

Device-specific periodReceiver Per 365 DAYS (continuous glucose system receiver)

Transmitter periodTransmitter Per 90 DAYS (continuous glucose system transmitter)

Topical cumulative quantity limits

Topical cumulative cap (desoximetasone group)100 Grams or 100 mLs Per 30 DAYS cumulative across listed desoximetasone agents

Individual topical entryDesoximetasone cream 0.25% = 100 Grams Per 30 DAYS

Gel/ointment/spray examplesDesoximetasone gel 0.05% = 90 Grams Per 30 DAYS; desoximetasone spray 0.25% = 100 mLs Per 30 DAYS

Dupilumab dispensing (examples)

Dupilumab (200 mg/1.14 mL) pens2 Pens Per 28 DAYS (2.28 mLs)

Dupilumab (300 mg/2 mL) syringes4 Syringes Per 28 DAYS (carton = 2 syringes = 4 mLs)

Formulary designationListed as Brand (B) for Dupixent entries

Longer interval dispensing example

Longer-interval example (fecal microbiota)Vowst = 12 Capsules Per 12 MONTHS

Starter-kit / 180-day exampleStarter Kits QL set up at NDC (e.g., edaravone starter kit = 70 mLs Per 180 DAYS)

Annual tablet pack exampleLenacapavir pack = 5 Tablets Per 365 DAYS

Common monthly caps

Common monthly cap for oral agentsMost oral agents: 30 or 60 units Per 30 DAYS

ExamplesDyanavel XR = 30 Tablets Per 30 DAYS; Adderall = 60 Tablets Per 30 DAYS

Alternate 90-day high limitSome agents show higher 30-day limits (eg. 90 Tablets Per 30 DAYS) depending on product

Oral triptan cumulative limit (reiterated)

Oral triptan cumulative capMaximum 18 Tablets Per 30 DAYS across all oral triptan agents

Example entriesAlmotriptan 12.5 mg = 18 Tablets Per 30 DAYS; Eletriptan/Eletriptan entries reference cumulative cap

Policy noteQuantity limit for oral triptans is cumulative across agents

Cumulative topical limits (examples)

Topical cumulative examplesHalcinonide cream 0.1% = 90 Grams Per 30 DAYS with 100/30 cumulative across agents

Halobetasol exampleHalobetasol propionate cream 0.05% = 150 Grams Per 90 DAYS (180/90 cumulative across agents)

Gentamicin exampleGentamicin sulfate cream 0.1% = 120 Grams Per 90 DAYS

Pen needle / syringe cumulative caps

Pen needle/syringe cumulative cap300 Units Per 30 DAYS (QL cumulative across all pen needles)

Insulin syringe cumulative cap300 Units Per 30 DAYS (applies cumulatively across insulin syringes)

Insulin pen needle examplesMultiple pen-needle SKUs listed with 300 Units Per 30 DAYS cap

Insulin syringe cumulative quantity limit

Insulin syringe cumulative QL300 Units Per 30 DAYS cumulative across insulin syringes

Insulin solution per 30-day exampleInsulin glargine (Lantus) = 100 mLs Per 30 DAYS (cumulative across injectable formulations)

Soliqua exampleSoliqua 100/33 = 6 Pens Per 30 DAYS (18 mLs)

Example dispensing thresholds (selected products)

Lasmiditan exampleLasmiditan 100 mg = 8 Tablets Per 30 DAYS

Lenacapavir exampleLenacapavir 300 mg = 4 Tablets Per 365 DAYS (pack = 5 tablets per 365 days)

Larotrectinib liquid exampleLarotrectinib oral solution = 300 mLs Per 30 DAYS

Maximum dispensing quantity examples

High-volume examples480 mL Per 30 DAYS (example: large liquid formulations); 120 Tablets Per 30 DAYS; 600 mLs Per 180 DAYS

Lopinavir-ritonavir example120 Tablets Per 30 DAYS (Kaletra)

Fenfluramine solution example360 mLs Per 30 DAYS (Fintepla)

Provider Responsibilities and Operational Notes

Documentation Required

Member financial responsibility and verification

If a prescription exceeds the stated dispensing limit, the member may obtain the full prescribed quantity but will be responsible for the full cost of any amount beyond coverage. Verify member-specific limits and state/regulatory exceptions via plan materials or the member ID card prior to dispensing.

Limits may not apply to all members or may vary by state.
Some dispensing limits apply across multiple medications within a drug class (cumulative QL).
Specialty and certain other categories may be limited to 30-day supplies depending on the benefit plan.

Billing Rule

Dispensing limits — inhalers / tablets (operational examples)

Inhalers: common dispensing convention is expressed both as "Inhalers Per 30 DAYS" and as blister/ dose equivalents. Example conventions: 60 blisters = 1 inhaler = 30 doses; some entries list 60 blisters per 30 days or 240 blisters = 4 inhalers (240 doses). Typical inhaler/tablet examples from the list:

Albuterol HFA and Respiclick: Dispensing Limit = 2 Inhalers Per 30 DAYS (some SKUs also show 6 packages per 90 days).
Fluticasone (Diskus/ Ellipta) examples: 60 Blisters Per 30 DAYS (60 blisters = 1 inhaler = 60 doses); other strengths show 240 Blisters Per 30 DAYS = 4 inhalers.
Inhaler-with-sensor SKUs (e.g., Proair Digihaler, Armonair Digihaler) are listed with the same per-30-day inhaler limits.

Documentation Required

Weight- and dose-dependent limits for factor products

Certain factor and clotting-product dispensing limits are weight- and dose-dependent; limits are expressed as mL (or units) per 30 days and calculated based on patient weight and number of doses. Operational rules: determine patient weight and dosing frequency to compute the allowed mL/unit per 30 days. Example entries:

Antihemophilic factor recombinant (Xyntha, Xyntha Solofuse): Dispensing Limit = mL Per 30 DAYS, Dependent on patient weight and number of doses.
Factor products and some C1 esterase or hemophilia therapies require individualized QL calculation rather than a flat per-prescription cap.

Documentation Required

Dispensing limits and brand/generic indicators

Each product entry includes a dispensing limit and a formulary designation indicating brand/generic availability. Designation codes used in listings: BG = Generic and Brand available; B = Brand only; G = Generic only. Pharmacies should use the listed designator when determining coverage and reimbursement.

Examples from the list: many adalimumab and etanercept entries are marked B (Brand Only) or BG per SKU.
Tablet and inhaler entries similarly include BG/B/G flags to indicate whether substitution/generic options exist.

Documentation Required

Cumulative quantity limit notes

Some quantity limits are cumulative across strengths, formulations, or agents. When a QL is described as "cumulative across strengths" or "cumulative across agents/formulations," total dispensed quantity across the grouped items counts toward the period limit.

Azithromycin: QL cumulative across strengths (e.g., 60 tablets per 180 days cumulative across 250 mg and 500 mg formulations).
Triptans: quantity limit for oral triptans and triptan combinations is cumulative with a maximum of 18 tablets per 30 days across all oral triptans.
Fluocinonide topical and other topical QLs show cumulative caps (e.g., 100 g/30 days cumulative across agents).

Documentation Required

Special QL calculation note (C1 esterase inhibitor)

Special QL calculation rule for certain weight-based products: C1 esterase inhibitor QL is calculated using the CDC 90th percentile adult weight (averaged for men and women) and rounded to the nearest even dose to reduce waste. See the Special Clinical Criteria table for calculation details.

Example: C1 esterase inhibitor (Haegarda) listed with a note indicating *QL calculation based on CDC 90th percentile adult weight; rounding rules applied.

Billing Rule

Dispensing limits listing — operational guidance

The dispensing limits list provides product-level caps (quantity per period) with the BG/B/G designation for each SKU. Use the per-product dispensing limit entries to determine covered quantity and substitution rules; when a product-level entry specifies cumulative or kit/carton rules, apply those operational rules at fill time.

Per-product caps include examples such as: 30 Tablets Per 30 DAYS, 2 Inhalers Per 30 DAYS, 28 Syringes Per 28 DAYS, 100 mLs Per 30 DAYS (insulins).
Some entries specify multiple conventions for the same product (e.g., inhaler = blisters mapping) — follow the explicit per-SKU instruction in the list.

Denial Risk

Cumulative triptan limit

Oral triptan dispensing is limited cumulatively across agents: the combined maximum for oral triptans and triptan combinations is 18 tablets per 30 days. Apply this cumulative cap when multiple triptan products or strengths are dispensed in the same 30-day window.

Example: eletriptan (Relpax) and other oral triptans are included in the cumulative 18-tablet per 30 days limit.

Note

Dispensing limit table entries — formats and examples

Dispensing limit table entries (examples) show the typical formats and periods used throughout the list. When interpreting entries, note the unit (tablets, capsules, syringes, pens, vials, mLs, grams, patches, inhalers, blisters) and period (Per 30 DAYS, Per 28 DAYS, Per 90 DAYS, Per 365 DAYS).

Tablet examples: many oncology and chronic therapy tablets listed as 30 Tablets Per 30 DAYS, 60 Tablets Per 30 DAYS, or other flat-monthly caps.
Syringe/pen/vial examples: insulin pens and biologic syringes commonly listed as X Syringes or Pens Per 28 or 30 DAYS.
Topical/ophthalmic examples: grams or mLs per 30/90/180 days (e.g., gentamicin cream 120 Grams Per 90 DAYS; Xiidra 60 Vials Per 30 DAYS).

Billing Rule

Dispensing limit and formulary designation entries

Formulary designation and dispensing limit entries are used to inform reimbursement and substitution. The policy lists a BG/B/G flag adjacent to each product-specific dispensing limit entry — pharmacies must apply the designation when adjudicating claims.

Entries consistently show a dispensing limit followed by the designation (BG, B, or G).
When a product is marked B (Brand Only), substitution to generic is not indicated as covered; when BG, either may be available per plan rules.

Documentation Required

Inhaler dispensing conventions

Inhaler dispensing conventions are explicitly noted where applicable: some inhaler SKUs use a blister-count representation (e.g., 60 blisters = 1 inhaler = 30 or 60 doses) and others state "Inhaler Per 30 DAYS." Confirm the SKU-specific mapping between blisters, inhalers, and doses at dispensing.

Example mappings in the list: 60 blisters = 1 inhaler = 30 doses (or 60 doses where specified); 240 blisters = 4 inhalers = 240 doses.
Apply the specific SKU rule (blisters per period or inhalers per period) when calculating allowed quantity.

Billing Rule

Cumulative quantity rules for insulin

Insulin quantity limits are cumulative across injectable insulin formulations. Standard entries list 100 mLs Per 30 DAYS for many insulin products (vials and pens) and note that quantity limits are cumulative across injectable formulations. Insulin syringes have a separate cumulative syringe/unit cap.

Examples: Insulin glargine, insulin degludec and many other insulin products: Dispensing Limit = 100 mLs Per 30 DAYS; note "Quantity limit cumulative across injectable formulations."
Insulin syringes: Dispensing Limit = 300 Units Per 30 DAYS, QL cumulative for all insulin syringes.

Billing Rule

Quantity limits for listed products — examples

Quantity limits for listed products follow the per-SKU caps in the list; common examples include tablets per month, pens/syringes per month, topical grams per period, inhalers per month, and kits per longer periods.

Examples: lansoprazole Solutab 30 mg = 60 Tablets Per 30 DAYS; gentamicin cream 0.1% = 120 Grams Per 90 DAYS; aripiprazole 5 mg = 60 Tablets Per 30 DAYS.
Specialty kits: some maintenance or titration kits are limited by kit/carton over extended periods (see kit/carton rules).

Billing Rule

Kit / carton dispensing rules

Kit and carton dispensing rules: certain products are limited by kit or carton counts over extended periods rather than by individual unit counts. Apply kit/carton limits as stated (do not split kit allowances across fills to exceed the kit cap).

Interferon beta-1a Rebif Titration Pack: Dispensing Limit = Kit Per 180 DAYS.
Rebif Rebidose carton: Dispensing Limit = 12 Syringes Per 28 DAYS, 1 carton = 12 syringes, QL cumulative across strengths.
Do not dispense multiple kits or cartons within the stated kit/carton period that would exceed the allowed kit count.

Note

Product dispensing limits — examples

Additional product-level examples to illustrate common dispensing-limit patterns: tablets per 30 days, inhalers per 30 days, syringes/pens per 28–30 days, topical grams per 30–90 days, vials/mLs for injectables, and annual or 365-day caps where noted.

Adalimumab/Etanercept family: commonly Dispensing Limit = 2 Pens or 2 Syringes Per 28 DAYS or 8 Vials Per 28 DAYS depending on SKU.
Clopidogrel/other cardiology agents often follow 30 or 90 day tablet caps; oncology agents show higher capsule/tablet caps per 30 days (e.g., encorafenib 180 Capsules Per 30 DAYS).
Azithromycin examples show 60 Tablets Per 180 DAYS cumulative across strengths.

Documentation Required

Cumulative quantity rules and grouping

Dispensing-limit grouping and cumulative rules: some quantity limits are cumulative at grouping levels (e.g., across GPI groups, across injectable formulations, or cumulative across strengths/agents). Always check grouping/cumulative notes on the SKU line before approving fills.

Example grouping/ cumulative rules: letermovir — Quantity limit is cumulative at GPI 12 (200 tablets per 365 days).
Many topical and inhaled agents specify QL cumulative across agents or strengths; apply cumulative accounting across those grouped SKUs.

Billing Rule

Dispensing limit and brand/generic status — operational note

When adjudicating claims, apply the product-specific dispensing limit and the listed BG/B/G status. These two pieces drive whether an item is covered, whether substitution is allowed, and what quantity is payable within the plan period.

Dispensing Limit + BG/B/G designation are the operative fields for coverage decisions.
If a product is marked B (Brand Only), generic substitution is not represented as covered for that SKU; if BG, either may be allowable per plan rules.

Key Terms and Unit Conventions

Dispensing Limit — definition

Definition: Dispensing LimitMaximum quantity of a specific product that may be dispensed within the specified time period

ImplicationIf prescription exceeds the limit, member may purchase but is responsible for cost beyond coverage; verify plan-specific limits

Units acceptedLimits expressed in units appropriate to product (tablets, mLs, syringes, pens, blisters, kits)

Supply interval — examples

Supply interval examplesPer 30 DAYS; Per 28 DAYS; Per 180 DAYS (also Per 365 DAYS, Per 90 DAYS)

Device/annual intervalReceiver Per 365 DAYS (continuous glucose system receiver)

Monthly/quarterly device periodsTransmitter Per 90 DAYS; Pen/Injection devices often Per 28 DAYS

Dispensing Limit — concise definition

Definition (concise)Maximum quantity of a specific product that may be dispensed within the specified time period (e.g., Per 28 DAYS, Per 30 DAYS).

Expressed formatShown as '<quantity> <unit> Per <period>' (e.g., '30 Tablets Per 30 DAYS')

Applies toIndividual drug formulations, devices, kits, or cumulative groups as noted

BG / B / G designation (formulary applicability)

BG / B / G meaningBG = Generic and Brand; B = Brand only; G = Generic only

Presence on entriesEach product line shows the formulary designation indicating applicability of limit to brand/generic

UsageUsed to indicate whether the listed dispensing limit applies to brand, generic, or both versions

Quantity allowed per specified time period — unit examples

Quantity example formatExamples given as 'Tablets Per 30 DAYS' or 'mLs Per 30 DAYS' or 'Pens Per 28 DAYS'

Tablet example30 Tablets Per 30 DAYS (common)

mL example1.56 mLs Per 30 DAYS (abaloparatide injection)

Variable dispensing amounts for factor products

Factor product variabilityDispensing amounts for coagulation factor products expressed as mL Per 30 DAYS and depend on patient weight and number of doses

Special calculation noteSome C1 esterase inhibitor QLs use CDC 90th percentile adult weight for calculation and rounding

Example entriesCoagulation factor entries list 'mL Per 30 DAYS' with dependency on weight/doses

Maximum quantity format example

Example format'30 Tablets Per 30 DAYS' is the typical display of maximum quantity and timeframe

Other unit examples'2 Inhalers Per 30 DAYS'; '4 Syringes Per 28 DAYS'; '120 mLs Per 30 DAYS'

Usage noteApplied per product line to indicate the maximum dispensed in that interval

Product availability / status codes (BG/B/G)

Formulary status codesBG = Generic and Brand; B = Brand only; G = Generic only

Appears with each productStatus shown on product lines to guide reimbursement and dispensing rules

Interpreting 'BG'Indicates both branded and generic versions are within scope of the limit

Dispensing Limit (per-entry) definition

Per-entry dispensing limit definitionDispensing Limit = the maximum quantity of the listed formulation that may be dispensed within the specified days

Units acceptedGrams, Tablets, mLs, Syringes, Pens, Blisters, Kits, Packs

Applied per productEach product line lists its Dispensing Limit and formulary designation

BG / B / G abbreviations — explanation

BG/B/G explainedBG indicates the limit applies to both Generic and Brand; B = Brand only; G = Generic only

Displayed usageFormulary flags appear on each dispensing limit line to indicate applicability

Decision supportUsed for reimbursement decisions and plan applicability

BG / B / G — abbreviations

BG/B/G flags — shortBG = Generic and Brand; B = Brand only; G = Generic only

Displayed with each entryFlags included to indicate whether the dispensing limit applies to branded/generic versions

Used for formulary decisionsGuides whether a product limit applies to covered versions

Blister — inhaler unit mapping

Blister unit definition (inhalers)60 blisters = 1 inhaler = 30 doses (used to map blisters to inhaler/dose counts)

Inhaler exampleFluticasone Diskus: 60 Blisters Per 30 DAYS = 1 inhaler (60 doses)

Mapping purposeFacilitates expressing inhaler limits in blisters or inhaler units

Dispensing Limit — broad definition

Dispensing Limit — broad definitionMaximum quantity of a specific medication that may be dispensed within the stated time period (grams, tablets, mLs, syringes)

Applied to product linesEach product lists the limit and the period (e.g., Per 30 DAYS)

Cumulative notesSome limits are cumulative across strengths or related formulations as noted

Cumulative quantity limit — category

Cumulative quantity categoryQuantity limit cumulative across specified product category (e.g., pen needles, insulin syringes, injectable formulations)

Insulin syringes exampleInsulin syringe SKUs: 300 Units Per 30 DAYS cumulative across all insulin syringes

Pen needles exampleInsulin pen needles: 300 Units Per 30 DAYS cumulative across pen needles

QL cumulative — insulin syringes

Insulin syringe QL cumulative300 Units Per 30 DAYS (QL cumulative for all insulin syringes)

Carton note1 carton = 12 syringes (used for kit/carton limits)

Policy impactCumulative caps affect dispensing across related SKUs and formulations

Carton — definition and usage

Carton definition (example)1 carton = 12 syringes (used in interferon beta/Rebif carton entries)

Kit/carton usageSome products limited per Kit Per 180 DAYS or per Carton Per 28 DAYS

Rebif exampleRebif Rebidose = 12 Syringes Per 28 DAYS (1 carton = 12 syringes)

Dispensing Limit — concise restatement

Dispensing Limit — conciseMaximum number of units of the specified drug that may be dispensed within the stated time period (e.g., per 30 days, per 365 days)

Examples of unitsTablets, Capsules, mLs, Vials, Pens, Syringes, Patches, Blisters, Packs

Displayed per productShown alongside brand/generic flag for each product line

B / G / BG applicability indication

Applicability flags (B/G/BG)Indicates whether limit applies to Brand only (B), Generic only (G), or Both (BG)

Displayed with each entryUsed to indicate formulary applicability and for reimbursement decisions

Interpretation guidance'BG' means both branded and generic versions are within the scope of the listed limit

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyBasic Dispensing Limits (DL)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page