Quality Care Dosing (QCD) Guidelines List
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A dosing limits list that specifies per-product Quality Care Dosing (QCD) limits (typically per 30 days) and maximum daily doses for prescription drugs; applies to Blue Cross Blue Shield - Massachusetts members and providers administering or prescribing these drugs.
No material clinical or coverage changes in this revision.
Quality Care Dosing Coverage Rules
Per-product QCD and Maximum Daily Dose coverage rule
Coverage is provided up to the listed QCD Limit and Maximum Daily Dose for each product; products may also be annotated with PA, SP, ST, or Non‑Covered indicators.
Applies product-by-product; some products have PA (prior authorization), ST (step therapy), SP/SPO (specialty) or * indicating Non‑Covered; see product entry
QCD list entries and annotations
Covered with dosing limits and possible prior authorization or specialty requirements as annotated
Refer to the product table for per‑product numeric values and annotations.
QCD dispensing criteria
Covered when the dispensed quantity and daily dose do not exceed the listed QCD Limit and Maximum Daily Dose for the product
Many products also carry (PA), (SP)/(SPO), or (ST) modifiers indicating prior authorization, specialty pharmacy requirement, or step therapy; those program rules apply in addition to QCD limits.
This list uses annotation markers to indicate coverage status for individual drug entries. An entry marked with an asterisk (*) is designated as a Non‑Covered Drug. An entry marked with a double asterisk (**) is designated as a Drug Non‑Covered while under review. These markers appear throughout the QCD table and should be used to determine whether a product is eligible for coverage as listed.
Where a specific formulation is shown as excluded by age, the list notes this next to the product. Examples in the table include: AcipHex 20 mg and AcipHex Sprinkle 5/10 mg — "Excluded for 18 years and older"; aspirin/omeprazole (81/40 mg and 325/40 mg) — "Excluded for 18 years and older"; lansoprazole and omeprazole formulations similarly note exclusion for adults where indicated. Consult the product line in the QCD table for the exact formulation-level exclusion language.
Some non‑coverage or age‑exclusion notes apply only to particular formulations. For example, the aspirin/omeprazole combination and several oral proton‑pump inhibitor entries (lansoprazole, omeprazole, pantoprazole, Zegerid) are explicitly labeled "Excluded for 18 years and older". Other items are shown with an asterisk to indicate they are Non‑Covered; these are not covered regardless of age unless the formulary/main policy states otherwise.
Certain lines in the table are explicitly flagged as non‑covered. These appear as either * Non‑Covered Drug or ** Drug Non‑Covered while under review adjacent to the product lines. When present, these annotations indicate the product is currently excluded from coverage (single asterisk) or is not covered while the drug is under policy review (double asterisk).
When an entry is marked ** Drug Non‑Covered while under review, the product is excluded from coverage for the duration of the review period. Claims submitted for items so annotated may be denied until the review completes and the listing is updated. The single‑asterisk * Non‑Covered Drug indicates a standing non‑coverage designation that should be confirmed against the primary policy or formulary if coverage is being requested.
Legend reminder: * denotes a Non‑Covered Drug and ** denotes a Drug Non‑Covered while under review. These annotations are applied at the product line level within the QCD list and appear in multiple locations across the document.
Examples of oral proton pump inhibitor products shown as excluded for certain ages include: lansoprazole 30 mg ("Excluded for 18 years and older") and omeprazole 10/20/40 mg ("Excluded for 18 years and older"). The table also marks omeprazole/sodium bicarbonate and pantoprazole 20/40 mg with the same adult exclusion where noted. Review the specific product line for the exact excluded formulation and age statement.
Across the QCD table some entries are restated with explicit non‑coverage annotations. Products displayed with * or ** adjacent to the drug name are to be treated as non‑covered or non‑covered pending review, respectively, per the table entries. These designations override routine QCD coverage unless otherwise amended.
If a product line in the QCD table carries an asterisk (*), consult the main QCD policy and the payer formulary for confirmation of coverage status and any additional exclusion detail. The QCD list is an administrative dosing and coverage table; formulary or policy documents hold the authoritative coverage determinations for asterisk‑marked drugs.
For clarity, the table reiterates the meaning of the symbols: * = Non‑Covered Drug; ** = Drug Non‑Covered while under review. Users should reference these annotations when assessing whether a product is eligible for coverage under standard QCD rules.
When a product is designated as * Non‑Covered Drug or ** Drug Non‑Covered while under review in the QCD table, requests for that product will generally be denied consistent with the list. Providers should not expect routine coverage for items so marked unless and until the table is revised or an exception is granted through formal appeal or special authorization pathways.
Dispensing or billing requests where the dispensed quantity or the daily dose exceeds the listed QCD Limit (typically measured per 30 days unless otherwise noted) or the listed Maximum Daily Dose are inconsistent with the QCD guidance. Such requests may be denied or returned for correction; providers should ensure quantities and days supply comply with the numeric limits in the product entry.
Measurement Periods, Annotations, and Coding Notes
| PA | Prior Authorization required (document annotation) |
| SP | Specialty product (document annotation) |
| SPO | Specialty/other product annotation appearing in entries (e.g., Procrit®, Pegasys®) |
| ST | Step therapy required (document annotation) |
| * | Asterisk denotes Non-Covered Drug or special attention (per document legend) |
| ** | Drug non-covered while under review (per document legend) |
Prior Authorization, Step Therapy, Documentation, and Denial Risks
Prior Authorization Required
Many products in the QCD list are annotated with utilization-management flags. When a product is marked (PA) or (SP)/(SPO) the provider must obtain prior authorization per the payer's PA rules before coverage is approved. Products annotated (PA), (SP), (SPO) require prior authorization or specialty handling and may have drug-specific PA criteria — check the payer's drug-specific PA policy for required documentation and clinical criteria.
- Prior authorization is required for all drugs annotated with (PA) before coverage is provided.
- Specialty-designated products (SP, SPO) marked alongside (PA) require both PA and specialty pharmacy/site-of-care handling.
- For PA requests include clinical justification, dosing regimen, and how the request aligns with the product's QCD Limit and Maximum Daily Dose fields.
Step Therapy Applies to ST‑Marked Products
Products annotated with (ST) are subject to step therapy requirements. When an item is marked (ST), prescribers must follow the plan's step therapy rules (including documentation of trial and failure of required first-line agents) prior to coverage of the ST product.
- Step therapy applies to drugs annotated (ST).
- Examples in the list include Atelvia, Avandia, Brexafemme, Glyxambi, Jardiance, Kerendia, Xigduo XR.
- Document prior therapies and outcomes when submitting PA/override requests for ST-marked products.
Dose/Quantity Exceedance and Denial Risks
Claims or PA requests that exceed the listed QCD Limit (per 30 days unless otherwise noted) or the product's Maximum Daily Dose may be denied. Non-covered markers (*) and (**) indicate drugs that are non‑covered or non‑covered while under review and also may lead to denial if billed without exception approval.
- Reference the QCD Limit (field 1) and Maximum Daily Dose (field 2) on claims and PA submissions.
- Requests beyond the QCD Limit or Maximum Daily Dose may be denied per QCD policy.
- Entries marked '*' = Non‑Covered Drug; entries marked '**' = Drug Non‑Covered while under review — claims for these drugs may be denied without exception or prior review.
Documentation Required for PA / Override Requests
When requesting exceptions, overrides, or prior authorizations, include the QCD Limit and Maximum Daily Dose values from the QCD list, detailed dosing regimen, and clinical rationale. Documentation should specifically address why the requested quantity/dose exceeds the QCD limits or why step therapy or PA requirements should be waived.
- Include the drug's QCD Limit and Maximum Daily Dose on the PA/claim submission.
- Provide clinical justification, prior treatment history, and dosing regimen when requesting overrides.
- If requesting an exception to step therapy, document prior agents tried and clinical reasons for failure or intolerance.
QCD Limits, PA/SP Indicators, and Denial Risk
Products annotated with (PA) or (SP) are high‑utilization management items — providers must obtain PA and ensure submitted quantities conform to the QCD table. Non‑covered markers and items marked (PA) are at increased risk for denial if PA is not obtained or if doses exceed listed limits.
- PA/SP indicators on the drug line require prior authorization; do not dispense or bill expecting automatic coverage.
- Claims for PA‑required items billed without prior authorization may be denied.
- Ensure PA submissions reference the specific product formulation and the QCD Limit/Maximum Daily Dose to avoid denial.
Reference QCD and Maximum Daily Dose on Submission
Always reference the QCD Limit and Maximum Daily Dose on claims and PA submissions and retain supporting clinical documentation. Providers should follow drug‑specific PA policies for criteria and submit dosing details to facilitate timely review.
- Include QCD Limit and Maximum Daily Dose values on all PA and claim submissions.
- Follow drug‑specific PA criteria published by the payer when applicable.
- Documentation should be available to support any request for quantity or dose above the QCD values.
Definitions and Key Terms
Products Subject to Step Therapy
| Product | Coverage status / Notes |
|---|---|
| Products annotated with (ST) | |
| Step therapy requirement applies — see step therapy policy for specific step definitions (specific step requirements not listed in this excerpt). |
| Product | Coverage status / Notes |
|---|---|
| Avandia | |
| Atelvia | |
| Boniva (ST) |
| Product | Coverage status / Notes |
|---|---|
| Gemtesa (ST) | |
| Glyxambi (ST) | |
| Jardiance (ST) | |
| Kerendia (ST) | |
| Inpefa (listed as product in ST group) |
| Summary | Policy implication |
|---|---|
| Products annotated with (ST) require step therapy prior to coverage. | |
| Specific step therapy criteria and required prior steps are defined in separate step therapy policy sections (not included in this excerpt). |
| Product | Coverage status / Notes |
|---|---|
| pioglitazone (ST) | |
| pioglitazone-metformin (ST) |
| Product | Coverage status / Notes |
|---|---|
| Qulipta | |
| Segluromet | |
| Steglatro (ST) | |
| Steglujan (ST) |
| Products marked (ST) | Notes |
|---|---|
| Multiple products across the list are annotated (ST) | |
| Step therapy applies to entries annotated (ST); refer to step therapy program for required prior treatments and exceptions. |
| Product | Coverage status / Notes |
|---|---|
| Xigduo XR (ST) |
Per-Product Quantity Limits and Maximum Daily Dose (Selected Examples)
Policy Background
Background: This document provides per‑product dosing quantity limits (the QCD Limit, generally measured per 30 days unless otherwise noted) and a Maximum Daily Dose for each listed drug formulation. These numeric constraints are used to guide coverage, claims processing, and utilization management decisions for Blue Cross Blue Shield‑Massachusetts.
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