CurrentBlue Cross Blue Shield - MassachusettsPolicy N/A

Quality Care Dosing (QCD) Guidelines List — drug-specific quantity and daily limits

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Lists per-period quantity (QCD) limits and maximum daily doses for many prescription medications and indicates prior authorization (PA), step therapy (ST), specialty (SP/SPO) flags, and non-covered status; applicable to providers and pharmacies dispensing to BCBS MA members.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyQuality Care Dosing (QCD) Guidelines List — drug-specific quantity and daily limits

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAs of 1/1/2026

Next Review DateN/A

Key ActionObtain prior authorization when a product is annotated (PA) and include dosing, days supply, and clinical justification for requests exceeding listed QCD limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/1/2026document date

dose & maxentries include QCD & MaxDose

PA/SP/STauthorization flags present

* / **non-covered markers

30 daysstandard period

Coverage rules and quantity/dose limits

General coverage rules (listed dosing limits and management flags)

Coverage is governed by listed QCD limits and flags; products marked with '*' indicate non-covered or under-review status and PA/ST/SP flags indicate management requirements.

General QCD rules: Drugs are covered up to the listed QCD Limit (quantity per the listed interval, typically per 30 days) AND must not exceed the listed Maximum Daily Dose; products marked with '*' are Non-Covered Drug and '**' indicates Drug Non-Covered while under review.per-drug limits as listed

PA, ST, SP or SPO annotations shown with products denote prior authorization, step therapy, or specialty handling requirements which must be satisfied for coverage.

General QCD coverage rules

Coverage is governed by listed QCD limits and Maximum Daily Dose; utilization flags affect authorization requirements.

General coverage rules: A drug is subject to its QCD Limit (per 30 days unless otherwise noted) AND must not exceed the listed Maximum Daily Dose; drugs marked with (PA) require prior authorization, (ST) indicates step therapy applies, and (SP)/(SPO) indicates specialty pharmacy or specialty/office-administered handling.per-entry QCD and Maximum Daily Dose

Age-based exclusions where shown (e.g., 'Excluded for 18 years and older') also affect coverage.

Quantity and Dose Limits

Coverage for a listed drug is constrained by the following dosing/quantity rules:

QCD and Dose Limits: Dispensing must not exceed the listed QCD Limit for the product (expressed per the specified interval, commonly per 30 days) AND must not exceed the listed Maximum Daily Dose for that formulation/strength.per-drug values listed in product lines

Some products use alternate interval windows (e.g., 21, 22, 28, 56, 84 days) or kit-specific limits; see individual product entries for exact numeric values.

Utilization Management Flags

Utilization management flags that affect coverage:

PA / SP / ST Flags: If a product is annotated with (PA), (SP), (SPO) or (ST) the corresponding prior authorization, specialty handling (or specialty/office administration), or step therapy requirement applies and must be satisfied for coverage.flag presence

Flags are shown inline with products (e.g., (PA)(SPO)) and may also indicate specialty channel routing or additional documentation expectations.

Per-product QCD coverage rule

Coverage and limits are governed by per-product QCD limits and annotations; coverage may require PA/SP/SPO or be listed as non-covered.

Per-product rule: Each listed product is subject to its listed QCD Limit (1 = per the stated interval, typically per 30 days) AND its listed Maximum Daily Dose (2 = maximum daily dose) where provided; products marked '*' or '**' indicate non-coverage status.per-entry values

Specific numeric QCD limits and Maximum Daily Dose values are provided for each product entry in the list and must be used to determine allowable dispensing and authorization needs.

Entries in the QCD list that are annotated with a single asterisk (*) are identified in the document as Non-Covered Drug. The list uses this marker inline with product rows to indicate those products are not covered under the benefit unless an approved exception applies.

The document also includes a legend line showing the double-asterisk notation: ** = Drug Non-Covered while under review, which signals items under active review and not covered pending that review.

Some product rows include an asterisk (*) to signal non-coverage and additionally specify age-based exclusions in the same row. For example, several entries list formulations with parenthetical notes such as "(Excluded for 18 years and older)" alongside the product and its QCD values — indicating the product is not covered for members aged 18 years and older in those formulations.

The presence of (PA), (ST), or (SP) alongside an asterisk does not negate the non-covered annotation; it is an explicit exclusion or age-limited exclusion called out in the product line.

The policy uses two distinct asterisk markers: a single asterisk (*) denotes a Non-Covered Drug, while a double asterisk (**) denotes a Drug Non-Covered while under review. These markers are defined in the document legend and are applied consistently in the product list to indicate current coverage status or items temporarily not covered during review.

When a product line is marked with ** it indicates the drug is actively under review and coverage is not available during that review period; single * indicates a standing non-coverage designation.

The non-covered markers occur repeatedly throughout the QCD table: product rows and section dividers are followed at intervals by lines or headings that reiterate the meaning of the markers (e.g., '* Non-Covered Drug' and '** Drug Non-Covered while under review').

These repeats in the printed list serve as reminders that individual entries annotated with the asterisks carry the non-coverage status and may be subject to denial if submitted without an approved exception.

Legend: * = Non-Covered Drug; ** = Drug Non-Covered while under review. This brief legend appears in the document and is the authoritative explanation for the asterisk markers used in product rows.

Where the legend is shown, it applies to the product entries in the adjacent pages or sections and should be used to interpret any asterisked rows.

Across multiple sections the single- and double-asterisk markers are repeated alongside product listings and section breaks to emphasize coverage status. The document inserts these marker reminders in page headers or footers near blocks of products to ensure consistent interpretation.

These repeated marker lines are not separate coverage rules but are annotations to help readers identify which listed products are non-covered or under review at a glance.

Numerous products in the table are shown with an asterisk (*) directly next to the product name or strength. When present, the asterisk flags that specific product presentation as a Non-Covered Drug in the QCD list (for example, select strengths of Abilify MYCITE and many Fragmin presentations are shown with a leading asterisk).

Providers should treat any product line with an asterisk as excluded from coverage under the standard benefit unless the payer has issued an exception or other guidance.

Non-covered markers are explanatory annotations used to distinguish administrative coverage status from dosing or quantity limits. A starred product line does not imply a dosing limit change — rather it indicates the product is not covered (single *) or is not covered while under review (**).

The QCD list uses these markers in lieu of separate clinical criteria for non-coverage; the legend and repeated headings provide the policy context for those entries.

Example: Zegerid 20 mg and 40 mg are listed with an asterisk and the parenthetical notation "(Excluded for 18 years and older)", meaning those strengths are not covered for members aged 18 years and older as shown in the product row.

The asterisk markers appear repeatedly on product rows throughout the list. Their repetition underscores that non-coverage is assessed at the specific product/presentation level (strength, formulation or kit) rather than applying uniformly across a brand.

When an item is starred, verify the exact formulation/strength row to confirm the non-coverage designation for that presentation.

This excerpt does not present explicit clinical criteria labeled "not medically necessary." Instead, coverage is determined by the combination of the QCD limit, the listed Maximum Daily Dose, and annotations including * (Non-Covered) or PA/ST/SP flags. The document states that no medical necessity criteria are included in this segment.

Several product lines combine the non-covered marker with an explicit age exclusion (e.g., Dexilant, Nexium, pantoprazole, and Zegerid entries indicate "(Excluded for 18 years and older)"). Where that language appears on a product row, coverage is excluded for the specified age group for that formulation.

Providers should confirm the member age and the exact product formulation prior to dispensing when age-based exclusions are indicated.

Codes, annotation legend, and QCD period

No procedure or billing codes in this excerptmixed

No codes listed

No procedure/diagnosis/billing codes present in this excerptmixed

No codes listed

Annotations used in listmixed

PA	Prior Authorization required (annotation in list)
SP	Specialty product designation
SPO	Specialty product/office-administered designation
ST	Step therapy required (annotation)
*	Non-covered drug marker
**	Drug non-covered while under review

Per-30-day QCD limit (per-entry value varies by drug)

Standard QCD periodPer 30 days (varies by drug; the QCD Limit value is shown for each drug entry)

Per-entry variabilityQCD limit numeric value differs by product and formulation (see individual drug rows)

Reporting conventionEntries use '1 = QCD Limit (Per 30 days unless otherwise noted)' to denote the standard quantity limit

QCD period — Per 30 days unless otherwise noted

Default intervalPer 30 days unless otherwise noted

Notation in tableThe document indicates '1 = QCD Limit (Per 30 days unless otherwise noted)' for entries

Exceptions existSome product lines specify alternate intervals when noted on the row

QCD Limit period (per 30 days unless otherwise noted)

DefinitionQCD Limit reported as the allowed quantity per 30 days unless an alternate interval is specified on the product row

Table conventionQCD entries shown as '1 = QCD Limit (Per 30 days unless otherwise noted)'

Provider implicationDispensing must not exceed the listed QCD Limit for the indicated reporting period

Some products use alternate periods (examples: 21,22,28,56,84 days)

Alternate intervals usedSome products use alternate QCD periods such as 21, 22, 28, 56, or 84 days as specified on the product row

ExamplesAlendronate entries show per-21 or per-22 day windows; many biologic kits use per-28, per-56, or per-84 day intervals

DocumentationWhen an alternate period is shown, the QCD Limit applies to that specified interval rather than the default 30-day window

QCD Limit interval reiterated (Per 30 days)

Reiteration of intervalQCD Limits are applied per 30 days unless the product row explicitly states a different interval

Table labelingThe list consistently denotes QCD Limit as '1 = QCD Limit (Per 30 days unless otherwise noted)'

Action for claimsPharmacies should use the interval shown on the product row to calculate allowable days supply/quantity

QCD per 30 days (per-entry '1 = QCD Limit' convention)

Per-30-day QCD reportingMost entries reported as QCD per 30 days; product rows may show alternate intervals where applicable

Notation styleEntries use numeric labels: '1 = QCD Limit' and '2 = Maximum Daily Dose' to distinguish fields

Provider expectationRequests exceeding the listed per-interval QCD may require prior authorization or risk denial

QCD Limit interval (per 30 days unless noted)

Default reporting periodPer 30 days unless otherwise noted on the product row

ConsistencyThe document repeats the per-30-day standard across sections and examples

Check product rowsAlways confirm the row-specific interval for drugs with non-monthly supplies (e.g., 28, 56, 84 days)

QCD Limit reporting period (per 30 days unless noted)

Reporting period guidanceQCD Limits are reported per 30 days by default; rows show exceptions (e.g., Tremfya per 56 days, Ustekinumab per 56 or 84 days)

Labeling practiceThe '1 = QCD Limit' field is interpreted against the interval shown on each product row

Operational noteUse the row-specified period when calculating allowed quantity for dispensing and claims adjudication

Authorization, documentation, and denial risk guidance

Prior Authorization

Prior authorization / Specialty / Step therapy requirements

Many specialty and biologic products listed in this QCD table require prior authorization and often have specialty (SP/SPO) handling or site-of-care designations. When a product is marked (PA), (SP), (SPO) or (ST) in the QCD list the provider must follow the payer’s authorization, specialty routing, and step-therapy rules before dispensing.

Prior authorization required for drugs marked (PA) — examples throughout the list include many inhalers, injectables, and oral specialty agents.
Specialty pharmacy routing or site-of-care (SP/SPO) applies to many biologics — examples include adalimumab products, Humira®, Stelara/Ustekinumab, and multiple others.
Step therapy (ST) flags are used where indicated — examples include Actonel®, Farxiga®, and several chronic-care oral therapies.

Documentation Required

Required documentation for PA / SP requests

When a product carries a (PA) designation the request must include clinical justification and dosing details. For specialty or site-of-care products (SP or SPO) include documentation of intended infusion or administration site if applicable.

Provide diagnosis, prior treatments tried and failed (for ST when applicable), and the rationale for the requested agent (for PA).
Supply exact dosing regimen, strength, quantity requested, and frequency — match the QCD limit fields where relevant (per-30-day limits and Maximum Daily Dose).
For SP/SPO products include planned dispensing channel (specialty pharmacy vs. physician-administered), and any infusion or clinic scheduling needs.

Denial Risk

Quantity limits and exceedance documentation

Quantity limits and Maximum Daily Dose (QCD) in the list are enforceable. Requests exceeding the QCD limit or Maximum Daily Dose require explicit clinical justification and will trigger additional review and potential denial if not supported.

If requesting quantities above the listed QCD limit provide weight-based dosing, prescriber notes showing medical necessity, or a specialist consult note as applicable.
For dose-dense or accelerated regimens, include treatment protocol and expected duration to support above-limit dosing.
Be aware: exceeding QCD or Maximum Daily Dose is a common denial reason — include supporting lab values, prior response documentation, or prior authorization from specialty pharmacy when possible.

Denial Risk

Non-coverage and review indicators

Non-covered drugs and agents listed as under review are identified with an asterisk (*) or double-asterisk (**). Claims for non-covered medications or drugs under review may deny; do not assume coverage until payer confirms.

'*' = Non-covered drug; '**' = Drug non-covered while under review — check the list entry before submitting a PA.
If a product is non-covered, consider formulary alternatives or submit a coverage exception request with strong clinical rationale.
Confirm member’s plan benefits and use the payer’s prior authorization portal or specialty pharmacy contact for final determination.

Step Therapy

Step therapy requirements and documentation

Step therapy (ST) flags require verification that first-line or preferred therapies were tried and failed per the payer’s step edits. Include dates and outcomes of prior therapies when submitting a PA or override request.

List prior agents, dates of therapy, reason for discontinuation (e.g., lack of efficacy, adverse event), and relevant objective data.
For migraine, cardiometabolic, and osteoporosis agents (examples in the table) follow the specific step pathways documented by the payer.
If exemption to step therapy is requested, provide clinical contraindication evidence or specialist recommendation.

Documentation Required

Authorization fields and required dosing documentation

Follow the payer’s documentation expectations: include prescriber NPI, specialty, ICD-10 diagnosis codes, and the exact quantity/days supply requested. When requesting amounts above QCD, clearly state the requested daily dose and supporting clinical rationale.

Required: prescriber NPI and contact, diagnosis with supporting clinical notes, previous therapies tried and response.
Include drug-specific dosing calculations when quantity requested differs from QCD (e.g., mg/kg dosing, vial counts).
Attach lab results, weight/height, or imaging reports when pertinent to justify higher-than-listed doses.

Billing Rule

Submission routing for PA / SP / SPO products

Use the payer’s prior authorization system or specialty pharmacy intake for PA/SP/SPO products. For drugs designated (SPO) or requiring site-of-care review, coordinate with the payer to confirm whether physician-administered or specialty pharmacy dispensing is required.

Contact the payer’s specialty pharmacy or prior authorization unit for submission pathways and expected turnaround times.
When submitting for SPO products include proposed administration site and any applicable facility codes.
For bundled kits or starter packs, reference the exact kit name and quantity per the QCD entry to avoid mis-routing.

Note

Provider actions when flags are present

When PA/ST/SP flags are present the provider should expect a review window and potential requirement for peer-to-peer discussion if information is incomplete. Monitor the member’s benefits and prior authorization status before dispensing.

Do not dispense large quantities on assumption of retroactive coverage; follow payer guidance and await authorization when possible.
If urgent treatment is needed, indicate urgency on the PA and supply supporting clinical notes to expedite review.
Keep documentation of all communications and authorization numbers in the patient chart.

Prior Authorization

Action checklist

Summary — key takeaways for providers: products marked (PA), (SP), (SPO), or (ST) require prior authorization, specialty routing, or step-therapy adherence; QCD limits are enforced and exceeding them requires clear justification; non-covered markers indicate likely denial unless a coverage exception is approved.

Before prescribing, check the QCD table for PA/ST/SP/SPO flags and the listed QCD limits and Maximum Daily Dose.
Include complete dosing, prior therapy history, diagnosis codes, and supporting clinical documentation with all PA requests.
For non-covered or under-review items, seek formulary alternatives or submit a coverage exception with robust clinical justification.

Document purpose and scope

The dosing limits table is intended to standardize the allowable quantities dispensed per member over defined windows and to cap daily dosing for safety and utilization management. The per-entry QCD values and the listed Maximum Daily Dose fields together define the permitted dispensing amount and the safety ceiling for daily use.

Key terms and legend

QCD Limit definition

QCD Limit (definition)The Quantity Care Dosing (QCD) Limit is the allowed quantity of a drug supplied in the reporting period (per 30 days unless otherwise noted)

Table representationIn the list each product row denotes '1 = QCD Limit' which indicates the allowed supply for the stated interval

Impact on coverageCoverage is limited to the listed QCD Limit per the specified period unless an exception or prior authorization is granted

Maximum Daily Dose definition

Maximum Daily Dose (definition)The Maximum Daily Dose is the maximum permitted daily amount for the drug as listed in the table (denoted as '2 = Maximum Daily Dose')

Table usageEach product row may list '2 = Maximum Daily Dose' to cap daily exposure in addition to the QCD Limit

Clinical relevancePrescriptions that exceed the Maximum Daily Dose may be subject to denial or require clinical justification

QCD Limit (restate)

QCD Limit restatementQCD Limit equals the allowed quantity for the reporting interval (default per 30 days) and is shown as '1' on each product row

Per-product valuesNumeric QCD values differ by product and formulation and must be read from each row

DocumentationThe list's column convention is consistent across the document to support claims adjudication

Maximum Daily Dose (restate)

Maximum Daily Dose restatedMaximum Daily Dose is provided per product row as '2' and caps the amount allowable per day

EnforcementClaims exceeding the listed Maximum Daily Dose may trigger prior authorization or denial

Complement to QCDBoth QCD Limit (per interval) and Maximum Daily Dose must be satisfied for coverage

QCD Limit (format note)

Format note for QCDEntries use '1 = QCD Limit (Per 30 days unless otherwise noted)' to indicate the allowed supply interval and quantity

Table clarityAlternate intervals are specified inline for products that do not follow the 30-day default

Reader actionRefer to the product row for the exact QCD Limit and any non-standard interval

Maximum Daily Dose (format note)

Format note for Maximum Daily DoseMaximum Daily Dose is shown as '2 = Maximum Daily Dose' on each product row and provides the daily cap

Units and presentationMaximum Daily Dose units vary by formulation (tablets, mL, syringes, patches) and are shown per entry

Enforcement implicationBoth QCD and Maximum Daily Dose fields are used to determine allowable fills and days supply

QCD Limit and Maximum Daily Dose — combined definition

Combined definitionCoverage requires adherence to both the QCD Limit (quantity per specified interval) and the Maximum Daily Dose (daily cap) as listed for each product

Table fieldsThe list denotes '1 = QCD Limit' and '2 = Maximum Daily Dose' for each product/strength

Operational effectPrescribers and pharmacies must ensure both limits are respected or obtain prior authorization where indicated

Non-covered markers legend ('*' and '**')

'*' marker'*' indicates a Non-Covered Drug as shown in the document legend

'**' marker'**' indicates a Drug Non-Covered while under review

PlacementAsterisks appear inline with product rows and are explained in the legend near the table

QCD Limit (restated for later chunks)

QCD Limit reiteratedQCD Limit equals the allowed quantity for the stated interval (default per 30 days); see product rows for values

Document conventionThe list repeats the '1 = QCD Limit' convention across sections for consistency

Provider actionUse the QCD Limit and interval shown to determine allowable quantity on a claim

Maximum Daily Dose (restated for later chunks)

Maximum Daily Dose reiteratedMaximum Daily Dose is listed per product as a daily cap (denoted '2' on rows); verify units per formulation

ConsistencyThe Maximum Daily Dose field is present for most products to cap daily use in addition to interval QCD limits

Claims handlingAdjudicators should apply both the QCD Limit and Maximum Daily Dose when evaluating quantity

Products subject to step therapy

Product	Coverage note
Actonel (ST) — multiple strengths (e.g., 150 mg, 35 mg, 5/30 mg)
Atelvia DR (ST) 35 mg
Summary: Step therapy applies for products flagged (ST); examples shown above

Statement	Interpretation
Drugs annotated with (ST) are indicated in the QCD list
These products are subject to step therapy requirements prior to coverage per the payer's pharmacy programs

Example product	ST annotation / note
Dihydroergotamine (ST) — nasal spray 4 mg/mL, QCD = 1 package (8 units) per 22 days
Eucrisa appears with (ST) annotation in list segments (ST indicates step therapy applies)

General note	Implication
Products marked (ST) in the QCD list indicate step therapy requirements may apply.
Specific step sequences or required prior agents are not provided in this excerpt; follow the payer's step therapy program for details.

Product	Annotation
Migranal (ST) — 4 mg/mL, 1 = 1 package (8 units) per 22 days
Annotation indicates Migranal is flagged with (ST) and step therapy may apply before coverage

Statement	Application
Products annotated with (ST) in the list are subject to step therapy prior to coverage.
Providers should confirm step therapy requirements when a product is flagged (ST) before submitting for coverage.

Policy summary	Program implication
Drugs annotated with (ST) are subject to step therapy per the payer's pharmacy programs.
Step therapy may require trial of preferred/alternative therapies before coverage of the (ST)-flagged agent is approved.

Examples	Meaning
Actonel (ST); Atelvia (ST); Trijardy XR (ST); Verquvo (ST); Veozah (ST)
Products flagged (ST) may require trial of preferred therapies prior to coverage — check the QCD list and payer program for required steps.

Per-product quantity limits (QCD) and maximum daily doses

Abilify MYCITE (selected strengths) — 1 kit (30 tablets) per 30 days

Abilify MYCITE1 kit (30 tablets) per 30 days

ReferenceListed as '*Abilify MYCITE® 2,5,10... 1 = 1 kit (30 tablets)' in the QCD list

UnitsKit equals 30 tablets as the QCD Limit

Adalimumab-ADBM Psoriasis Kit 40mg/0.8mL — 4 autoinjectors/syringes per 28 days

Adalimumab-ADBM Psoriasis Kit 40mg/0.8mL4 autoinjectors/syringes per 28 days

Maximum Daily DoseMaximum Daily Dose = 0.143 syringes (as shown on product row)

FlagsEntry annotated (PA)(SPO)

Ajovy 225mg/1.5mL — 1 syringe per 28 days

Ajovy 225mg/1.5mL1 syringe/auto syringe per 28 days

Maximum Daily DoseMaximum Daily Dose = 0.054 mL

FlagEntry annotated (PA)

Adderall XR 20,30 mg — 60 capsules per 30 days

Adderall XR 20, 30 mg60 capsules per 30 days

Maximum Daily DoseMaximum Daily Dose = 2 capsules

Alternate strengthsOther XR strengths listed with different QCD (e.g., 5–25 mg = 30 capsules)

Azstarys — 30 capsules

Azstarys30 capsules per 30 days

Maximum Daily DoseMaximum Daily Dose = 1 capsule

PresentationMultiple strengths (26.1/5.2 mg; 39.2/7.8 mg; 52.3/10.4 mg) share the same QCD

Baqsimi — 2 units per 22 days

Baqsimi 3 mg2 units per 22 days

Maximum Daily DoseMaximum Daily Dose not listed for some formulations in the excerpt

Interval noteThis entry uses a 22-day interval rather than the 30-day default

Basaglar 100U Kwikpen — 45 mL (15 pens)

Basaglar 100U Kwikpen45 mL (15 pens) per 30 days

Maximum Daily DoseMaximum Daily Dose = 1.5 mL

Alternate presentationsBasaglar Tempo and other pen presentations share the same QCD

Cimzia 400mg vial kit — 3 kits (6 vials) per 28 days

Cimzia 400mg vial kit3 kits (6 vials) per 28 days

Maximum Daily DoseMaximum Daily Dose = 0.108 kits

FlagsEntry annotated (PA)(SPO)

Diabetic testing strips (all brands) — 300 strips

Diabetic testing strips (all brands)300 strips per 30 days

Maximum Daily DoseMaximum Daily Dose field shown as '2 = 10 strips' in the row

Coverage implicationStandard QCD period applies unless otherwise noted

Multiple (see drug_names and original chunks) — assorted QCD examples

Multiple QCD examplesThe list contains many product-specific QCD values (examples include autoinjectors per 28 days, 30 tablets per 30 days, 2 pens per 28 days, 8 patches per 28 days, etc.)

Read per rowEach drug/formulation row must be consulted for the exact QCD Limit and interval

Flags and exceptionsSome entries include PA, SP, SPO, ST, or non-covered markers which affect coverage and required actions

Granix prefilled syringes — 30 prefilled syringes

Granix prefilled syringes30 prefilled syringes per 30 days

PresentationsApplies to 300mcg/0.5mL and 480mcg/0.8mL prefilled syringe presentations as listed

Maximum Daily DoseMaximum Daily Dose = 1 syringe for some presentations

Harvoni — 28 tablets per 28 days

Harvoni (various strengths)28 tablets per 28 days

Maximum Daily DoseMaximum Daily Dose = 1 tablet

FlagsEntries annotated (PA)(SP)

Humalog vials/cartridges/Kwikpen — various examples

Humalog presentationsExamples include vials 40 mL, cartridges/Kwikpen 45 mL, 200U pens 24 mL (QCD varies by presentation)

Maximum Daily DoseMaximum Daily Dose examples: 1.5 mL for many Humalog pen/cartridge presentations

Reference rowsSee Humalog rows for the exact QCD per presentation in the list

Impavido — 3 cartons (84 capsules) per 22 days

Impavido 50 mg3 cartons (84 capsules) per 22 days

Maximum Daily DoseMaximum Daily Dose not specified in the excerpt for this product

Interval noteUses a 22-day interval rather than the 30-day default

Impavido 50mg — 3 cartons (84 capsules) per 22 days

Impavido 50mg (entry)3 cartons (84 capsules) per 22 days

Same as Impavido rowListed similarly elsewhere in the same chunk with identical QCD

Coverage noteFollow the per-22-day QCD interval for this product

Imuldosa 45mg/0.5mL vial — 1 vial per 84 days

Imuldosa 45mg/0.5mL vial1 vial per 84 days

Maximum Daily DoseMaximum Daily Dose = 0.006 mL for 45mg/0.5mL vial entries

FlagsAnnotations include (PA)(SPO) on these rows

Inpefa 200mg, 400mg — 30 tablets per 30 days

Inpefa 200mg, 400mg30 tablets per 30 days

Maximum Daily DoseMaximum Daily Dose = 1 tablet

FlagEntry annotated (ST) in the excerpt

Indomethacin 20mg — 90 capsules per 30 days

Indomethacin 20 mg90 capsules per 30 days

Maximum Daily DoseMaximum Daily Dose = 3 capsules

NotationListed with standard per-30-day QCD Limit

Mavyret 100mg/40mg — 84 tablets per 28 days

Mavyret 100mg/40mg84 tablets per 28 days

Maximum Daily DoseMaximum Daily Dose = 2.8 tablets

FlagsEntry annotated (PA)(SP)

Lyllana (various strengths) — 8 patches

Lyllana (various strengths)8 patches per 28 days

Maximum Daily DoseMaximum Daily Dose = 0.286 patch

PresentationMultiple patch strengths listed share the same QCD

Mavyret 100mg/40mg — 84 tablets (alternate chunk)

Mavyret (alternate row)84 tablets per 28 days (alternate listing)

Maximum Daily DoseMaximum Daily Dose = 2.8 tablets

See alsoMultiple Mavyret presentations/pellet packs listed in the document

Mounjaro (pens) — 4 pens

Mounjaro (pens)4 pens per 28 days

Maximum Daily DoseMaximum Daily Dose = 0.072 mL

FlagEntry annotated (PA)

Novolog FlexPen 100U/mL — 45 mL

Novolog FlexPen 100U/mL45 mL per 30 days

Maximum Daily DoseMaximum Daily Dose = 1.5 mL for FlexPen and many Novolog presentations

Alternate presentationsNovolog cartridges and vials have similar but distinct QCD entries (e.g., 45 mL cartridges; 40 mL vials)

ondansetron 4 mg/5 mL solution — 150 mL

ondansetron 4 mg/5 mL solution150 mL per Rx

Maximum Daily DoseMaximum Daily Dose for solution form listed as 5 mL in the table

Other formulationsODT and tablet forms have separate QCD entries (e.g., 24 tablets per Rx for ODT forms)

Example entries from list — QCD/Maximum Daily Dose convention

QCD/Maximum Daily Dose conventionEntries follow '1 = QCD Limit (Per 30 days unless otherwise noted)' and '2 = Maximum Daily Dose' across the list

ExamplesIndividual rows provide specific numeric values (e.g., Otezla 30 mg shows 1 = 60 tablets, 2 = 2 tablets)

Provider useUse both fields to evaluate allowable dispensing and prior authorization needs

Repatha 140mg/mL Sureclick — 2 pens per 28 days

Repatha 140 mg/mL Sureclick2 pens per 28 days

Maximum Daily DoseMaximum Daily Dose = 0.072 mL

Alternate presentation420 mg Pushtronex QCD = 1 syringe per 28 days (listed separately)

Sofosbuvir/Velpatasvir 90/400mg — 28 tablets per 28 days

Sofosbuvir/Velpatasvir 90/400 mg28 tablets per 28 days

Maximum Daily DoseMaximum Daily Dose = 1 tablet

FlagsEntry annotated (PA)(SP)

Tresiba 100U/mL vial — 40mL

Tresiba 100U/mL vial40 mL per 30 days

Maximum Daily DoseMaximum Daily Dose = 1.334 mL

Alternate presentationsFlexTouch packs listed as 45 mL (3 packs) in other rows

Tremfya (100mg/mL) — 1 syringe/autoinjector per 56 days

Tremfya (100 mg/mL)1 syringe/autoinjector per 56 days

Maximum Daily DoseMaximum Daily Dose = 0.002 mL for 100 mg/mL presentation

FlagsEntry annotated (PA)(SPO)

Ustekinumab (multiple brands) — 1 vial/syringe per 84 days or 1 syringe per 56 days

Ustekinumab (multiple brands)1 vial/syringe per 84 days or 1 syringe per 56 days depending on formulation

Maximum Daily DoseMaximum Daily Dose values vary by presentation (e.g., 0.006 mL for 45 mg/0.5 mL)

FlagsEntries annotated (PA)(SPO)

Wegovy — 4 pens per 30 days (varies by strength)

Wegovy4 pens per 30 days (varies by strength)

Maximum Daily DoseMaximum Daily Dose depends on pen strength and is shown on the product row

FlagEntry annotated (PA) or (SP) where applicable in full document

Zepbound — 4 pens/autoinjectors per 28 days

Zepbound4 autoinjectors per 28 days (various presentations) or 4 pen injectors per 28 days

Maximum Daily DoseMaximum Daily Dose varies by presentation (examples: 0.072 mL, 0.086 mL), shown on product row

FlagsEntry annotated (PA) in the list

Zavzpret — 8 units

Zavzpret8 units (QCD Limit) as listed

IntervalEntry shown with QCD Limit = 8 units (per 22 days in chunk 162)

FlagEntry annotated (PA)

Zegerid — 60 capsules/packets

Zegerid60 capsules/packets per 30 days

Maximum Daily DoseMaximum Daily Dose = 2 capsules/packets

Age exclusionEntry notes exclusion for 18 years and older for listed strengths

Zeposia — 30 capsules

Zeposia30 capsules per 30 days

Maximum Daily DoseMaximum Daily Dose = 1 capsule

FlagEntry annotated (PA) in the list

zolmitriptan 2.5 mg — 12 tablets

zolmitriptan 2.5 mg12 tablets per 22 days

Alternate formsODT and nasal spray forms have separate QCD entries (e.g., ODT 12 tablets per 22 days; nasal spray devices 6 per 22 days)

Maximum Daily DoseMaximum Daily Dose not specified for some zolmitriptan entries in excerpt

Zurzuvae 20/25 mg — 28 capsules

Zurzuvae 20/25 mg28 capsules per year (SP designation) as listed

Interval noteThis product's QCD in the excerpt is shown per year for some strengths (e.g., 28 capsules per year)

FlagEntry annotated (SP) indicating specialty handling

Billing Rule

Route SP/SPO products through specialty channels

Specialty-designated products (SP/SPO) noted in the QCD list are managed through specialty channels and may require specialty pharmacy handling or infusion center routing per the annotation.

Specialty and infusion handling

Billing Rule

Specialty-designated products handled via specialty channels

Products designated SP or SPO in the list are managed through specialty programs and must be handled via specialty channels (e.g., infusion center or specialty pharmacy) as annotated.

Biosimilar references and handling

Billing Rule

Adalimumab biosimilars marked PA/SPO — require PA and specialty handling

Adalimumab reference and biosimilar entries include QCD limits and are annotated with (PA) and (SPO) where applicable, indicating they require managed coverage and prior authorization through specialty channels.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyQuality Care Dosing (QCD) Guidelines List — drug-specific quantity and daily limits

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAs of 1/1/2026

Next Review DateN/A

Key ActionObtain prior authorization when a product is annotated (PA) and include dosing, days supply, and clinical justification for requests exceeding listed QCD limits.

SourceLink

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