CurrentBlue Cross Blue Shield - MichiganPolicy N/A

Quantity Limit Program (drug quantity limits)

Defines quantity limits for medications on BCBSM and BCN drug lists (Clinical, Closed, Custom, Custom Select, Preferred). Applies to prescribing, dispensing, and billing for members covered under these formularies; member-specific benefit limits may vary.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyQuantity Limit Program (drug quantity limits)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFebruary 2026

Next Review DateN/A

Key ActionReview the member's specific benefit and drug-list to confirm the applicable quantity limits before dispensing and billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90opioid daily morphine milligram equivalent limit

0.5 mlcommon vaccine limit per fill (examples)

1common inhaler/month limit (examples)

~200+drug-specific quantity-limit lines in this part

list-specificlimits differ by BCBSM/BCN and list type

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Policy Snapshot & Scope

This part defines the Quantity Limit Program for medications on Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network (BCN) formularies. It applies to prescribing, dispensing and billing for members covered under BCBSM and BCN drug lists including Clinical, Custom, Closed, Custom Select, and BCN Preferred where listed; quantities are aligned with FDA dosing guidance and may vary by the member’s specific drug list and plan.

Policy metadata

Policy titleQuantity Limit Program (drug quantity limits)

Payerblue cross blue shield - michigan

Policy NumberN/A

Effective DateFebruary 2026

StatusCURRENT

Quantity Limit Program — Criteria

This part is a quantity limits listing rather than a set of nested medical necessity criteria trees. It provides per-product and per-formulary limits (per day, per 28/30 days, per fill, per 365 days, or per course) and notes when products are marked Not covered or Not applicable for specific drug lists.

Drugs, Formulations and Quantity Limits

drugs and supplies with explicit quantity limits in this partmixed

Caplyta (lumateperone)	1 tablet per day for BCBSM and BCN Preferred
Capvaxive (Pneumococcal 21-Valent Vaccine, Diphtheria Conjugate)	0.5 ml per fill across BCBSM/BCN lists shown
Caverject (alprostadil)	12 vials/units per 30 days on most lists; Not covered on BCBSM Custom Select
Cayston (aztreonam)	84 vials per 28 days
Cequa (cyclosporine)	1 box (60 vials) per 30 days
Cequr Simplicity 2 U kit	8 units per 30 days
Cequr Simplicity Inserter	1 inserter per 90 days
Cerdelga (eliglustat)	56 capsules per 30 days
Chantix (varenicline)	2 tablets per day
Chicken pox vaccine (Varivax)	0.5 ml per Rx

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Drugs and quantity limits (selected from this part)mixed

Gonal-f RFF 75 units (follitropin alfa)	Custom Select: 10 vials/30 days; 30 vials/365 days. Other lists: Not applicable or Not applicable depending on list.
Gonal-f RFF Pen 300 units (follitropin alfa)	Custom Select: 15 cartridges/30 days; 45 cartridges/365 days.
Gonal-f RFF Pen 450 units (follitropin alfa)	Custom Select: 10 cartridges/30 days; 30 cartridges/365 days.
Gonal-f RFF Pen 900 units (follitropin alfa)	Custom Select: 5 cartridges/30 days; 15 cartridges/365 days.
Gralise starter pack (gabapentin)	Clinical/Custom/Closed and BCN Preferred: 78 tablets/365 days. BCBSM Custom Select: Not covered.
Gralise 300mg, 600mg (gabapentin)	Clinical/Custom/Closed and BCN Preferred: 3 tablets/day. BCBSM Custom Select: Not covered.
Gralise 450,750,900mg (gabapentin)	Clinical/Custom/Closed and BCN Preferred: 2 tablets/day. BCBSM Custom Select: Not covered.
Grastek (timothy grass pollen allergen extract)	Clinical/Custom/Closed and BCN Preferred: 1 tablet/day. BCBSM Custom Select: Not covered.
Gvoke Syringe / Hypopen (glucagon)	8 units/30 days; 16 units/365 days across lists.
Gynol II (nonoxinol 9)	1 package (81 grams)/30 days across lists.

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Key thresholds and limits

opioid_mme_daily_limit90 morphine milligram equivalent per day

Acetaminophen daily max for combination opioid products4 grams per day

Initial opioid/controlled short-fill limit5 day supply for first fill; 30 day supply for subsequent fills

Shingrix interval2 vial kits per 720 days

First-fill limit (selected products)Zohydro ER limited to 5 day supply for the first fill

Annual limits (examples)Yeztugo 4 tablets per 365 days; Zegalogue 16 injections per 365 days; Zeposia starter kit 1 per 365 days

Billing & Pharmacy Actions — What Providers Must Do

Documentation Required

Follow formulary-specific coverage

Check member's plan formulary (BCBSM vs BCN and which drug list applies) to determine which quantity limit or coverage status (including Not covered) applies before dispensing and billing.

Billing Rule

Adhere to formulary-specific quantity limits

Pharmacy claims must comply with the drug-specific quantity limits and coverage status based on the member's formulary (Clinical, Custom, Closed, Custom Select, BCN Preferred). Some Custom Select listings are 'Not covered' while others permit quantities; check member's drug list.

Key Terms & Definitions

Definitions

Quantity Limit ProgramProgram that sets quantity limits for medications consistent with FDA-approved dosing guidelines for drugs on BCBSM and BCN drug lists.

Drug ListsFormulary lists referenced include BCBSM Clinical, Custom, Closed, Custom Select Drug Lists and BCBSM/BCN Preferred and BCN Custom, Closed, Custom Select Drug Lists.

Quantity limitThe maximum amount of a drug allowed per defined time period (per day, per 30 days, per 365 days, per fill) as stated for each formulary/list.

Custom Select Drug ListA plan-specific formulary tier referenced in the quantity limits; coverage and limits may differ and some products may be marked 'Not covered'.

Clinical/Custom/Closed Drug ListsFormulary designations used by BCBSM/BCN to determine coverage and quantity limits.

BCN Preferred Drug List

Clinical / Administrative Background

The document lists explicit quantity limits across BCBSM and BCN drug lists as part of the payer’s broader Prior Authorization and Step Therapy coverage materials. It states the program promotes safe medication use, aligns limits with FDA dosing guidance, and includes systemwide constraints such as an opioid limit of 90 MME/day and initial-fill restrictions (for example, many opioids are limited to a 5‑day supply for the first fill with 30‑day subsequent fills).

Document Dates & Changes

Effective: February 2026. Last review: —. Next review: —.