CurrentBlue Cross Blue Shield - MassachusettsPolicy N/A

Quality Care Dosing (QCD) Guidelines List

A formulary-style list that specifies per-product Quality Care Dosing (QCD) quantity limits (generally per 30 days or other interval) and maximum daily doses for pharmacy-covered drugs; intended for providers and pharmacies administering or prescribing these products to Blue Cross Blue Shield Massachusetts members.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyQuality Care Dosing (QCD) Guidelines List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization when a product is annotated with (PA) and ensure submitted dosing and quantity match the listed QCD Limit and Maximum Daily Dose.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

manydrug entries

per 30 daysdefault interval

multiplePA/SP flags

someNon-Covered flags

multipleQCD entries listed

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.

Coverage Criteria and QCD Rules

General coverage requirements (dosing/authorization)

Products are covered subject to the listed QCD limit and maximum daily dose; many specialty/biologic agents also require prior authorization as indicated.

QCD limit and max daily dose: Dispensing must not exceed the listed QCD Limit (per 30 days unless otherwise noted) AND must not exceed the listed Maximum Daily Dose for each product.per-product values listed

Some products have alternate intervals (e.g., per 28 days or per 21 days) as noted in the product entry.

Prior authorization: If a product is annotated with (PA), prior authorization is required before coverage.PA annotation

Specialty products may also be annotated (SPO) indicating specialty pharmacy handling.

QCD-limited covered drugs (examples)

Drugs are covered subject to the listed QCD limit and maximum daily dose; PA/SP/SPO designations apply as indicated.

Example: Emgality: Emgality (PA) 300 mg/mL: QCD Limit = 1 = 3 mL; Maximum Daily Dose = 2 = 0.1 mLQCD per 30 days and max daily mL as shown

see product line

Example: Enbrel / Enbrele: Enbrel (PA) (SPO) 25 mg kit: QCD Limit = 1 = 8 vials per 28 days; Enbrele (PA) (SPO) 50 mg syringe: QCD Limit = 1 = 4.08 mL (4 syringes) per 28 days; Maximum Daily Dose values included per lineper product

see product lines

Example: Humira / Humalog: Humira (PA) (SPO) 40 mg/0.4 mL: QCD Limit = 2 syringes per 28 days (Maximum Daily Dose = 0.72 syringe); Humalog Kwikpen: QCD Limit = 45 mL per 30 days (Maximum Daily Dose = 1.5 mL)per product

see product lines

Per-product QCD and Maximum Daily Dose compliance

Coverage applies when dispensed within the listed QCD Limit and not exceeding the listed Maximum Daily Dose for the exact product/formulation.

Per-product QCD compliance: Dispense quantity must be <= the listed QCD Limit for the specified formulation and time period (typically per 28 or 30 days).See per-product QCD Limit entry

Entries indicate formulation (vial, pen, syringe, kit) and often include (PA)/(SPO)/(SP) flags.

Per-product QCD coverage

Coverage follows listed QCD limits and maximum daily doses for each product line; some products are flagged as PA (prior authorization) or SP (specialty) and some lines are marked Non-Covered while under review.

Per-product coverage rules: For each drug product entry, coverage is limited to the listed QCD Limit (usually per 30 days) AND the listed Maximum Daily Dose. Products flagged 'PA' require prior authorization; 'SP' indicates specialty handling. Entries marked 'Non-Covered Drug' are not covered while under review.QCD Limit + Maximum Daily Dose

See individual line items in the list for exact numeric limits and form-specific notes

General coverage rule

Coverage and claim adjudication should follow the listed QCD Limit and Maximum Daily Dose values for each product

Per-product dosing limits: For a given drug entry, coverage is constrained to the QCD Limit (per 30 days unless otherwise noted) AND the Maximum Daily Dose as listed; PA or SP markers indicate additional prior authorization or specialty handling may be required.per product values

See individual product lines in the policy for exact numbers and any age-based exclusions or Non-Covered markers.

Entries explicitly labeled Non-Covered Drug or annotated as ** Drug Non-Covered while under review are excluded from coverage for the duration of the review. Claims submitted for products flagged this way are at risk for denial while the product remains under review and should not be considered covered until the review is complete.

The marker ** Non-Covered Drug indicates a temporary exclusion: the drug is not covered while it is under internal review. This marker appears on multiple line items to signal that coverage will not be provided for those products until the review status changes.

When a line item is shown under the heading Non-Covered Drug (often followed by the note ** Drug Non-Covered while under review), that product is explicitly excluded from coverage during the review period. Providers should expect claim denials for these specific entries if submitted while the non‑covered designation remains in effect.

The list contains multiple instances where the section label Non-Covered Drug (sometimes with the appended phrase ** Drug Non-Covered while under review) is used to mark products that are not eligible for coverage pending review. These section markers serve as a direct exclusion indicator on the formulary extract.

Some product lines include age-based exclusion language alongside the non-coverage designation. For example, omeprazole 10, 20, 40 mg is listed with the note (Excluded for 18 and older) and a QCD Limit of 60 capsules per 30 days, indicating coverage is not provided for members aged 18 years and older.

Certain entries are explicitly restricted by age. The policy lists products such as pantoprazole 20/40 mg and others with the label (Excluded for 18 years and older), meaning those formulations are not covered for members who are 18 years or older as shown on the line item.

The document uses repeated section markers labeled Non-Covered Drug to group and call out products that are excluded from coverage while under review. These markers typically precede the affected line items and are intended to clearly identify temporary non‑coverage status for reviewers and claims personnel.

Later sections of the list continue to use the Non-Covered Drug label and the explanatory phrase ** Drug Non-Covered while under review. These repeated labels indicate multiple, distinct entries throughout the document that are temporarily non‑covered under the QCD listing.

Multiple discrete entries across the extract are flagged as Non-Covered Drug (often with the appended ** Drug Non-Covered while under review note), showing that several products are being reviewed and are not currently eligible for coverage. The presence of several such entries indicates this is a recurring status applied to individual line items throughout the list.

Coding, Measurement Periods and Identifiers

Policy annotationsmixed

PA	Prior Authorization required (annotation shown next to many products)
SP	Specialty product annotation

Policy annotations (duplicate source summary)mixed

PA	Prior Authorization required (annotation shown next to many products)
SP	Specialty product annotation

Policy markers and flagsmixed

PA	Prior Authorization required (marker shown beside many products)
SP	Specialty product marker (shown beside many products)
ST	Step Therapy marker (appears next to some products)
Non-Covered	Marker indicating drug is non-covered while under review

inv-17: QCD Limit interval — Per 30 days unless otherwise noted

QCD Limit intervalPer 30 days unless otherwise noted

Typical exceptionsSome product lines specify Per 28 days or other intervals as noted on the product line

Usage note'Drug Product, 1' field denotes the QCD Limit and uses the interval above unless the line explicitly overrides it

inv-18: QCD Limit (Per 30 days unless otherwise noted)

QCD Limit (general)Varies by product; default reporting period is per 30 days unless otherwise noted

Product examplesEntries such as Emgality, Enbrel, Humalog show per-product QCD Limits in mL, syringes, pens, or tablets

Provider Requirements, Prior Authorization, and Denial Risk

Prior Authorization

Prior authorization required for PA/SPO/SP products

Prior authorization is required for products annotated with (PA), (SPO), or (SP). Verify PA designation on the product line before submitting a claim or dispensing the product.

Applies to any drug in the QCD list annotated with (PA), (SPO), or (SP).
Examples: products listed as (PA), (PA) (SP), (PA) (SPO), or (SP) in the QCD table.

Prior Authorization

Prior authorization required for PA/SP products

Prior authorization is required for products annotated as (PA) or (SP). Confirm both PA and specialty pharmacy (SP/SPO) designations and follow the payer's PA submission process when either annotation is present.

When either (PA) or (SP) appears next to a product, a PA must be obtained prior to coverage.
Specialty-designated products (SP or SPO) may have additional dispensing or site-of-care requirements.

Background and Purpose

Background: This document is a Quality Care Dosing (QCD) dosing and quantity limits list that defines per‑product quantity limits (QCD Limit, typically per 30 days unless otherwise noted) and Maximum Daily Dose values to guide dispensing and coverage for Blue Cross Blue Shield Massachusetts members. Many products are annotated with program markers such as (PA) for prior authorization and (SPO)/(SP) for specialty handling; select items are marked Non-Covered Drug indicating temporary non‑coverage while under review.

Definitions

inv-59: Definition — QCD Limit

QCD Limit (definition)Quantity limit applied under the Quality Care Dosing (QCD) program; default interval is Per 30 days unless otherwise noted.

Identified fieldIn the document, 'Drug Product, 1' corresponds to the QCD Limit value for each product line.

Use in adjudicationClaims should be reviewed against the listed QCD Limit for the specified interval to determine coverage eligibility.

inv-60: Definition — Maximum Daily Dose

Maximum Daily Dose (definition)Maximum allowable daily amount specified for the product (document field 'Drug Product, 2').

Formulation-specificMaximum Daily Dose is given per formulation (e.g., tablets/day, mL/day, patches/day) and must not be exceeded for coverage.

Step Therapy Indicators

Product	Annotation(s)	Notes
Advair Diskus
(PA)
Listed with (PA) in product line; QCD limits and maximum daily dose provided per formulation (see product entry).

Example Product	Step therapy marker	Source note
Invokamet
(ST)
Invokamet appears with (ST) in the quantity limits list indicating step therapy may apply (see product lines).
Migranal
(ST)
Migranal is shown with (ST) in the document extract (step therapy marker present).

Flag	Meaning	Details in excerpt
(ST)
Step therapy marker
The document includes (ST) markers for some products; specific step rules are not included in the provided excerpt.

Per-Product Quantity Limits (QCD) and Max Daily Doses

inv-64: Abilify MYCITES 2,5,10,15,20,30 mg — QCD entry

Abilify MYCITES — QCD Limit1 kit (30 tablets) per 30 days

Maximum Daily Dose (Abilify MYCITES)Tablet (per product line '2' field)

Source notePolicy header lists Abilify MYCITES with the QCD Limit and Maximum Daily Dose fields (chunk 0)

inv-65: Adalimumab-ADBM 40mg/0.8ml Psoriasis Kit — QCD entry

Adalimumab-ADBM Psoriasis Kit — QCD Limit4 autoinjectors/syringes per 28 days

Maximum Daily Dose0.143 syringes (per product line)

PA/SPO designation

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyQuality Care Dosing (QCD) Guidelines List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization when a product is annotated with (PA) and ensure submitted dosing and quantity match the listed QCD Limit and Maximum Daily Dose.

SourceLink

On This Page

Example: Glucose testing strips / Fiasp: Glucose testing strips (all brands): QCD Limit = 300 strips per 30 days; Fiasp cartridge example: QCD Limit = 48 mL; Maximum Daily Dose values shown per lineper product

Provider actionPrescriptions should not exceed the listed QCD Limit for the specified interval

inv-19: Maximum Daily Dose (per-product)

Maximum Daily Dose (definition)Maximum allowable daily amount specified per product (varies by formulation)

Insulin exampleBasaglar 100U Kwikpen: Maximum Daily Dose = 1.5 mls (per chunk 18)

Humalog exampleHumalog Kwikpen: Maximum Daily Dose = 1.5 mls (per chunk 54)

inv-20: QCD Limit reporting period — Per 28 or Per 30 days noted

QCD reporting periods usedDocument uses Per 28 days and Per 30 days reporting periods depending on product entries

Examples per 28 daysAdalimumab kits and many biologics list QCD Limit per 28 days (chunk 4)

Examples per 30 daysHumalog, Humuline and many insulin entries use Per 30 days (chunks 54,55)

inv-21: QCD measurement period — Per 30 days unless otherwise noted

QCD measurement period (policy default)Per 30 days unless otherwise noted

Document examplesMultiple entries reiterate Per 30 days as the measurement window (see chunks 72,76)

Deviation handlingIf a product line specifies a different interval (e.g., 28 days or 56 days), that interval supersedes the default for that product

inv-22: QCD Limit (additional chunk group)

Per-product QCD limits vary by drugQCD Limit (Per 30 days unless otherwise noted) is specified per drug line and can differ substantially between products

See product examplesOrserdu, Otezla, Saxenda and others list specific QCD Limits per product line (chunks 90,109)

Provider implicationAdjudicate claims using the exact QCD Limit and interval shown for each product

inv-23: Maximum Daily Dose (additional chunk group)

Maximum Daily Dose varies by formulationMaximum Daily Dose is listed per product/formulation (pens, vials, cartridges, tablets) and must be observed for coverage

Insulin examplesInsulin Aspart Penfill/FlexPen: Max Daily Dose = 1.5 mls; Insulin Glargine 300 U/mL: Max Daily Dose = 0.467 mL (chunks 63,64)

Biologic examplesSkyrizi 60 mg: Maximum Daily Dose = 0.4 mls; Saxenda 6 mg/mL pen: Max Daily Dose = 0.5 mls (chunks 112,109)

inv-24: QCD Limit / Maximum Daily Dose pattern across entries

Pattern across entriesEach drug entry reports two primary fields: '1 = QCD Limit (Per 30 days unless otherwise noted)' and '2 = Maximum Daily Dose'

Formulation specificityLimits are formulation-specific (e.g., mL for insulin cartridges, number of syringes/pens for biologics, tablets for oral agents)

Interval overridesSome agents use non‑monthly intervals (e.g., 56 or 84 days) which are shown on the product line and must be applied instead of the default

inv-25: QCD Limit interval (repeat)

Default interval restatedPolicy header and multiple entries confirm: QCD Limit is per 30 days unless otherwise noted

Apply per-product exceptionsWhen a product line explicitly states a different period (e.g., per 28 days), use that interval for adjudication

Documentation guidanceProviders/pharmacies should document quantity and daily dose consistent with the interval shown on the product line

Prior Authorization

Prior authorization requirements

Prior authorization requirements apply to many entries in the QCD list and must be confirmed before dispensing. Failure to obtain required PA may result in claim denial or member liability.

PA is indicated where (PA) appears in the product listing.
Review the product line for PA annotations and submit documentation supporting medical necessity.

Prior Authorization

Prior authorization requirement (PA annotation reminder)

Products annotated with (PA) in the QCD list indicate a prior authorization requirement. Check the specific product row for PA/SPO/SP flags and follow PA submission instructions.

The presence of (PA) in the product listing is the trigger for the PA requirement.
PA may be required in combination with specialty pharmacy designations (SP, SPO).

Denial Risk

Non-Covered while under review

Drugs listed as Non-Covered while under review are not covered until the review and any required prior authorization are complete. Do not assume coverage for fills submitted without an approved PA.

Lines marked 'Non-Covered Drug' or '** Drug Non-Covered while under review' indicate drugs that may be denied while PA is pending.
If PA is denied or not submitted, the dispensed drug may be the member's financial responsibility.

Prior Authorization

Prior authorization indicated (PA annotation)

The QCD list uses PA, SP, and SPO annotations to indicate when prior authorization and/or specialty pharmacy handling are required. Always verify annotations on the product row and use them to guide submission routing.

PA = prior authorization required; SP = specialty pharmacy; SPO = specialty pharmacy office/other specialty handling.
Confirm both PA and SP/SPO before dispensing or initiating therapy.

Documentation Required

Required dosing/quantity alignment

Dose and quantity on the prescription must align with the QCD limits and Maximum Daily Dose shown in the product table. Submit dosing and quantity details with PA requests to avoid delays or denials.

Provide exact dosing (mg or mL), quantity per fill, days supply, and intended dosing frequency in the PA documentation.
If the prescribed dose or quantity exceeds the QCD limit or Maximum Daily Dose, include clinical justification and supporting documentation.

Prior Authorization

PA / Specialty designations

Adhere to QCD limits and specialty designations when preparing PA requests and dispensing. Specialty products (SP/SPO) may require specific pharmacy networks or prior authorization workflows.

Follow specialty pharmacy routing for SP/SPO products; claims submitted to non-specialty pharmacies may deny.
QCD limits are per 30 days unless otherwise noted; observe alternate interval notes (e.g., per 28 days, per 84 days) on product rows.

Documentation Required

QCD limit documentation

Document the Quality Care Dosing (QCD) limit and Maximum Daily Dose field values in the PA and pharmacy claim to support dosing validation and claim adjudication.

Include the QCD limit (per 30 days or specified interval) and Maximum Daily Dose values from the product table in the PA request.
If dispensing a different quantity or dose than the QCD specifies, provide clinical rationale and supporting records.

Documentation Required

Required documentation for dosing validation

Required documentation for dosing validation must be included with prior authorization submissions. This helps ensure timely review and reduces the risk of denial for over-limit fills.

Submit clinical notes, diagnosis codes, prior treatments, and rationale for doses or quantities exceeding QCD limits.
When applicable, include weight-based dosing calculations, monitoring plans, and specialist consultation notes.

Documentation Required

Dose and quantity documentation (provider instruction)

Provide dose, quantity, days supply, and any calculation used to determine dosing in the PA and pharmacy documentation. Clear, complete dose and quantity information expedites review and adjudication.

Dose (mg or mL), frequency, total quantity dispensed, and days supply must be present on the prescription and PA form.
If the request exceeds QCD or Maximum Daily Dose limits, include specific clinical justification and supporting chart notes.

Role in coveragePrescriptions exceeding the Maximum Daily Dose are subject to denial per policy guidance.

Entry is annotated (PA) (SPO) indicating prior authorization and specialty handling

inv-66: Basaglar 100U Kwikpen — QCD entry

Basaglar 100U Kwikpen — QCD Limit45 mL (15 pens) per 30 days

Maximum Daily Dose1.5 mls

Alternate presentationsBasaglar Tempo 10OU pen also listed with 45 mL per 30 days and max 1.5 mls (chunk 18)

inv-67: Basaglar 100U Kwikpen — alternate line QCD entry

Basaglar 100U Kwikpen (alternate line) — QCD Limit45 mL per 30 days (15 pens)

Maximum Daily Dose1.5 mls

Consistency noteMultiple Basaglar lines repeat the same QCD and maximum daily dose values (chunk 18)

inv-68: Breo Ellipta (blisters) — QCD entry

Breo Ellipta (blisters) — QCD Limit60 blisters per 30 days

Maximum Daily Dose2 blisters

Source linesBreo Ellipta QCD and max dose shown in chunk 19 (and similar inhaler entries in chunk 36)

inv-69: buprenorphine (SL/patch/film forms) — QCD entry

Buprenorphine (SL/patch/film) — QCD LimitVaries by formulation (examples: 60 sublingual tablets; 4 patches per 28 days; 60 films)

Maximum Daily DoseSpecified per formulation on the product line (see chunks 22,32)

Formulation examplesButrans patches and buprenorphine films/tablets are listed with distinct QCD Limits and max daily doses

inv-70: Diabetic testing strips (all brands) — QCD entry

Diabetic/Glucose testing strips — QCD Limit300 strips per 30 days

Maximum Daily Dose10 strips per day

Applies toAll brands of testing strips as listed in the policy (chunks 32,52)

inv-71: Enbrel (various presentations) — QCD entry examples

Enbrel (various) — QCD LimitVaries by presentation (examples: 8 vials per 28 days; 4 syringes/4.08 mL per 28 days)

Maximum Daily DoseFormulation-specific values shown per line (e.g., 0.286 vials; 0.146 mls)

PA/SPO designationMany Enbrel entries are annotated (PA) (SPO) indicating prior authorization/specialty handling

inv-72: Glucose testing strips (all brands) — QCD entry

Glucose testing strips (duplicate) — QCD Limit300 strips per 30 days

Maximum Daily Dose10 strips per day

Document locationListed again in chunk 52 confirming the same limit

inv-73: Fiasp cartridge — QCD entry

Fiasp cartridge — QCD Limit48 mL (example line) or 45 mL for some cartridge entries; specific lines show 48 mL per 30 days

Maximum Daily DoseExamples: Fiasp U100 cartridge Maximum Daily Dose = 1.6 mls; other Fiasp cartridge entries show 1.5 mls or 1.334 mls depending on formulation

Multiple entriesDocument includes several Fiasp/Fiaspe lines with formulation‑specific limits (chunk 42)

inv-74: Humira (40 mg/0.4 mL) — QCD entry

Humira 40 mg/0.4 mL — QCD Limit2 syringes per 28 days

Maximum Daily Dose0.72 syringe (per product line)

PA/SPO annotationHumira entries are annotated (PA) (SPO) across multiple formulations (chunks 55,54)

inv-75: Humalog Kwikpen — QCD entry

Humalog Kwikpen — QCD Limit45 mL per 30 days

Maximum Daily Dose1.5 mls

Related linesHumalog vials, cartridges and Tempo pen entries show corresponding per‑formulation QCD and max daily dose values (chunk 54)

inv-76: Humira 40mg/0.4mL syringe — QCD entry

Humira 40mg/0.4mL syringe — QCD Limit2 syringes per 28 days

Maximum Daily Dose0.72 syringe

Multiple formulationsHumira also listed as pens, kits, and starter packs with distinct QCD Limits and max daily doses (chunk 55)

inv-77: Insulin Aspart (Penfill/FlexPen, vial) — QCD entry

Insulin Aspart (Penfill/FlexPen, vial) — QCD Limit45 mL (penfill)/40 mL (vial) per 30 days

Maximum Daily DosePenfill/FlexPen 1.5 mls; vial 1.334 mls

Source linesInsulin Aspart limits are listed in chunk 63 and related insulin entries in chunk 64

inv-78: Insulin Glargine 300 U/mL — QCD entry

Insulin Glargine 300 U/mL — QCD Limit13.5 mL per 30 days

Maximum Daily Dose0.467 mL (standard) or 0.6 mL for MAX presentation (chunk 64)

Related entriesGlargine 300 U/mL MAX shows 18 mL QCD and higher max daily dose (chunk 64)

inv-79: Invokamet / Invokana / Jakafi / Jaypirca examples — QCD entries

Invokamet / Invokana / Jakafi / Jaypirca examples — QCD LimitVaries by product; typical QCD Limits shown include 30–90 tablets per 30 days depending on product and strength

Maximum Daily DoseProduct‑specific (e.g., Invokamet max = 2 tablets), see individual lines

ST/PA flagsSome entries include (ST) or (PA)/(SP) annotations — check the product line for authorization requirements

inv-80: Lexapro 5,10,20 mg — QCD entry

Lexapro 5/10/20 mg — QCD Limit45 tablets per 30 days

Maximum Daily Dose1.5 tablets

Formulation noteStandard oral tablet limits shown in chunk 72

inv-81: lidocaine patch 5% — QCD entry

Lidocaine patch 5% — QCD Limit90 patches per 30 days

Maximum Daily Dose3 patches per day

Multiple packaging sizesSeveral tube/patch sizes listed with corresponding gram-based max daily doses (chunk 72)

inv-82: Liraglutide 8mg/3ml (2 pack) — QCD entry

Liraglutide 8mg/3ml (2 pack) — QCD Limit6 mL per 28 days

Maximum Daily Dose0.215 mls (per product line)

PA annotationLiraglutide entries are annotated (PA) in the document (chunk 72)

inv-83: methylphenidate ER 36 mg — QCD entry

Methylphenidate ER 36 mg — QCD Limit120 tablets per 30 days

Maximum Daily DosePer product line (chunk 76) — listed as tablet maximum daily dose

Coverage noteHigh QCD Limit for specific ER strengths noted in chunk 76

inv-84: Novolog FlexPen 100U/ml — QCD entry

Novolog FlexPen 100U/ml — QCD Limit45 mL per 30 days

Maximum Daily Dose1.5 mls

Related insulin linesNovolog and Novolin vials/cartridges show similar per‑formulation QCD and maximum daily dose values (chunk 83)

inv-85: ozempic (PA) 2 mg/3 ml — QCD entry

Ozempic (PA) 2 mg/3 mL — QCD Limit3 mL per 28 days (or 3 mL per 21 days on specific Ozempic line); multiple Ozempic entries present

Maximum Daily Dose0.108 mls (per Ozempic product lines)

PA annotationOzempic entries annotated (PA) — prior authorization required where shown

inv-86: Orserdu 345 mg — QCD entry

Orserdu 345 mg — QCD Limit30 tablets per 30 days

Maximum Daily Dose1 tablet (per product line)

PA designationOrserdu listed with (PA) annotation in chunk 90 referencing prior authorization (see chunk 90/110 context)

inv-87: Otezla 10/20/30 mg — QCD entry

Otezla 10/20/30 mg — QCD Limit60 tablets per 30 days

Maximum Daily Dose2 tablets per day

PA/SP annotationsOtezla lines include (PA) (SP) for some pack types and starter packs with distinct QCD Limits

inv-88: Saxenda 6 mg/mL pen — QCD entry

Saxenda 6 mg/mL pen — QCD Limit15 mL per 30 days

Maximum Daily Dose0.5 mls per day

PA annotationSaxenda is annotated (PA) in the document (chunk 109)

inv-89: pantoprazole 20/40 mg (>=18 yrs excluded) — QCD entry

Pantoprazole 20/40 mg (age exclusion) — QCD Limit60 tablets/packets

Age-based exclusionEntry explicitly states 'Excluded for 18 years and older' on the line (chunk 92)

Maximum Daily Dose2 tablets/packets per day

inv-90: Saxenda (6 mg/ml pen) — QCD entry (duplicate)

Saxenda (duplicate) — QCD Limit15 mL per 30 days

Maximum Daily Dose0.5 mls per day

Policy noteSaxenda appears multiple times in the list with the same limits (chunk 109)

inv-91: Siliq (210 mg/1.5 ml) — QCD entry

Siliq 210 mg/1.5 mL — QCD Limit2 packs (4 syringes) per 30 days

Maximum Daily Dose0.215 mls per day

PA annotationSiliq is annotated (PA) indicating prior authorization is required (chunk 110)

inv-92: Skyrizi (60 mg) — QCD entry

Skyrizi 60 mg — QCD Limit1 vial (10 mL) per 28 days

Maximum Daily Dose0.4 mls per day

PA/SPO annotationsSkyrizi entries annotated (PA) (SPO) for many presentations (chunk 112)

inv-93: sumatriptan 25/50/100 mg — QCD entry

Sumatriptan 25/50/100 mg — QCD Limit9 tablets per 22 days (for specific oral formulations)

Maximum Daily DosePer product line — see chunk 63/116 for formulation‑specific max daily doses

Alternate formsNasal spray, cartridges and injection forms have separate QCD Limits and intervals (chunks 63,116)

inv-94: Tremfya (100 mg/ml) — QCD entry

Tremfya (100 mg/mL) — QCD Limit1 syringe/autoinjector per 56 days

Maximum Daily Dose0.002–0.036 mls depending on presentation (see chunk 120)

PA/SPO annotationTremfya entries annotated (PA) (SPO) for many presentations (chunk 120)

inv-95: Ustekinumab (90 mg/ml) — QCD entry

Ustekinumab 90 mg/mL — QCD LimitSyringe per 56 days (per chunk 124)

Maximum Daily Dose0.02 mls per day (per chunk 124)

PA/SPO designationUstekinumab entries are annotated (PA) (SPO) — prior authorization/specialty handling applies

inv-96: Ventolin HFA 90 mcg/act — QCD entry

Ventolin HFA 90 mcg/act — QCD Limit2 inhalers per 30 days

Maximum Daily Dose1.2 grams (per inhaler formulation line)

Coverage noteVentolin HFA entries may repeat across the document with the same QCD Limit (chunk 126)

inv-97: Ventolin HFA 90 mcg — QCD entry (repeat)

Ventolin HFA 90 mcg — QCD Limit2 inhalers per month

Maximum Daily Dose1.2 grams (per chunk 126)

Repeat entriesMultiple Ventolin HFA lines exist in the document with similar limits (chunks 126,140)

inv-98: Vumerity (SP) DR 231 mg — QCD entry

Vumerity (SP) DR 231 mg — QCD Limit120 capsules per 30 days

Maximum Daily Dose4 capsules per day

SP designationAnnotated (SP) indicating specialty handling (chunk 129)

inv-99: Zocorc (simvastatin) 5-80 mg — QCD entry

Zocorc (simvastatin) 5-80 mg — QCD Limit30 tablets per 30 days

Maximum Daily Dose1 tablet per day (per product line)

Document noteStandard oral statin entry listed with 30-tablet QCD limit (chunk 112)