15-Day Specialty Drug Limitation Program
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Limits days' supply for listed specialty drugs for BCBSM and BCN members: initial six fills are limited to 15-day supplies, with the seventh fill permitted as 15- or 30-day (or plan default). Applicable to members subject to the payer's pharmacy coverage and may require prior authorization.
No material clinical or coverage changes in this revision.
Coverage Criteria
Dispensing quantity criteria
Covered when these dispensing rules are followed:
Members pay half copay for 15-day supply.
Members pay full copay for 30-day supply; members who had six 15-day fills within last six months qualify for up to a 30-day supply.
This policy applies to the drugs listed on the payer’s 15‑Day Specialty Drug List. There are no separate clinical exclusions specified in the policy text; coverage and dispensing limits are defined solely by the program’s day‑supply rules for listed specialty medications.
Initial Therapy
Initial therapy
Initial dispensing rules
Some drugs may also require prior authorization.
Continuation / Ongoing Therapy
Ongoing therapy supply allowance
Continuation/ongoing therapy dispensing rules tied to fill count:
Applies at or after the seventh fill.
Quantity Limits and Drug List
Provider Actions and Billing Guidance
Obtain prior authorization when required
Some drugs included in the 15-Day Specialty Drug Limitation Program require prior authorization; obtain a PA when the drug’s coverage rules require it.
No step-therapy pathway specified
Step therapy requirements are not specified in this policy beyond the 15-day supply limitation and the possibility that certain drugs may require prior authorization.
Document fill history to determine 30-day eligibility
Document the patient’s prior fill history (number of 15-day fills) to confirm eligibility for a 30-day supply at the seventh fill; prior authorization may also be required.
- Members who have had six 15-day supply prescriptions filled within the last six months qualify for up to a 30-day supply.
- Record the count of prior 15-day fills to determine whether the seventh fill may be dispensed as 30 days.
Risk of denial if day‑supply limits exceeded
Dispensing more than the allowed day supply for the first six fills (greater than a 15-day supply) risks denial or non-reimbursement under the program.
- Initial six fills are limited to a 15-day supply; do not dispense >15 days for those fills.
- Seventh fill allowance changes; verify member’s prior fill history before dispensing a 30-day supply.
Definitions
Background
The program is an administrative measure intended to reduce member out‑of‑pocket costs and medication waste by limiting initial dispensing quantities for certain specialty drugs. Under the program, listed drugs are limited to a 15‑day supply for the first six fills, with the seventh fill allowed as a 15‑ or 30‑day supply (or the group’s default). The policy notes that these drugs may require prior authorization and that members who receive six 15‑day fills within six months become eligible for up to a 30‑day supply.
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