CurrentBlue Cross Blue Shield - MichiganPolicy N/A

15-Day Specialty Drug Limitation Program

Limits initial dispensing of designated specialty drugs to a 15-day supply for the first six fills, describes copay differences and transition to larger fills at the seventh fill; applies to Blue Cross Blue Shield of Michigan and Blue Care Network members and their providers.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

Policy15-Day Specialty Drug Limitation Program

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical changes

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionFor the first six fills, dispense no more than a 15-day supply; document six 15-day fills within six months to allow up to a 30-day supply at the seventh fill.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15-dayinitial days' supply limit

6 fillslimited fills

7th fill30-day eligibility

half copaycopay for 15-day

may require prior authorizationprior auth

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Coverage Criteria

Dispensing and copay criteria

Covered when ALL of the following are met:

Program criteria: 1) Drug is on the 15-Day Specialty Drug List; 2) For the first through sixth fills, the drug is limited to a 15-day supply; 3) On the seventh fill, the drug may be dispensed as either a 15-day supply or up to a 30-day supply (or the group default day-supply limit); 4) Members who have had six 15-day supply prescriptions filled within the last six months qualify for up to a 30-day supply.

Members pay half copayment for a 15-day supply and full copayment for a 30-day supply. Some drugs on the list may require prior authorization.

This program applies only to medications that are specifically listed on the 15-Day Specialty Drug List. Drugs not named on that list are not subject to the 15-day limitation program and are excluded from these dispensing and copayment rules.

Initial Therapy

Initial dispensing is limited as follows:

Initial fills: Drugs included in the 15-Day Specialty Drug Limitation Program are limited to a 15-day supply for each of the first six fills.6 fills

Members pay half copayment for the 15-day supply during these initial fills.

Continuation / Transition

Continuation/Transition

Transition from initial limited fills:

Transition to standard day supply: After completing six 15-day fills (within the last six months), members qualify for up to a 30-day supply beginning with the seventh fill; at the seventh fill the plan allows either a 15-day or a 30-day supply (or the group default day-supply limit).6 fills

Member copayment differs by supply length (half copay for 15-day, full copay for 30-day).

Provider Actions and Requirements

Prior Authorization

Prior Authorization May Be Required

Some drugs on the 15-day Specialty Drug Limitation Program may require prior authorization. Check the plan's drug list and prior authorization requirements before dispensing.

Prior authorization required where noted by the plan.

Step Therapy

Step Therapy Note

This program enforces day‑supply limits and does not operate as a clinical step‑therapy sequence.

Step therapy sequencing is not applicable; limits are based on fill count and day‑supply.
Program enforces 15‑day limits for the first six fills rather than clinical step edits.

Quantity Limits

Listed specialty drugs — 15-day supply program summary

Program limitDrugs on the 15-Day Specialty Drug List are limited to a 15-day supply for the first six fills.

Seventh fill ruleOn the seventh fill the drug may be dispensed as either a 15-day supply or a 30-day supply (or the group’s default day-supply limit).

Member cost shareMembers pay half of their copayment for a 15-day supply and the full copayment for a 30-day supply.

Transition qualificationMembers who have had six 15-day supply prescriptions filled within the last six months qualify for up to a 30-day supply.

Prior authorizationSome drugs on the 15-day program may require prior authorization as noted by the plan.

Definitions

15-Day Specialty Drug Limitation Program — definition

Definition15-Day Specialty Drug Limitation Program: a limitation that restricts dispensing to a maximum 15-day supply for the first six fills of listed specialty drugs.

PurposeDesigned to help members save on copays and reduce medication waste by limiting initial days' supply for specified specialty drugs.

ScopeApplies only to drugs named on the 15-Day Specialty Drug List; some listed drugs may require prior authorization.

Eligibility for extended supplyAfter six 15-day fills (within the last six months), members qualify for up to a 30-day supply beginning with the seventh fill.

Background

The 15-Day Specialty Drug Limitation Program is an administrative, cost-management policy designed to limit dispensed day supply for selected specialty medications to help Blue Cross Blue Shield of Michigan and Blue Care Network members reduce copay costs and medication waste. Under the program, listed drugs are limited to a 15-day supply for the first six fills. Beginning with the seventh fill, the drug may be dispensed as either a 15-day supply or a 30-day supply (or the group’s default day-supply limit). Members pay half of their copayment for a 15-day supply and the full copayment for a 30-day supply. Members who have had six 15-day supply prescriptions filled within the last six months qualify for up to a 30-day supply. Some drugs on the list may require prior authorization.

Step Therapy

Step	Description	Coverage status
No clinical step-therapy sequencing is described; the program enforces day-supply limits rather than step requirements.	Drugs on the 15-Day Specialty Drug List are limited to a 15-day supply for the first six fills. On the seventh fill, drugs may be dispensed as a 15-day supply or up to a 30-day supply (or the group default day-supply limit). Members who have had six 15-day fills within the last six months qualify for up to a 30-day supply.	Covered