Blue Cross Blue Shield NM dispensing limits Coverage

General Dispensing Limit Coverage

Covered when ALL of the following are met:

Default dispensing limit rule: A drug is covered up to the listed dispensing limit (quantity per specified time period). If prescribed quantity exceeds the listed dispensing limit, the member may obtain the medication but will be responsible for the full cost beyond what coverage allows.per-entry limit as listed

Limits and plan applicability may vary by member plan and state; see plan materials or call number on member ID.

Dispensing Limit Criteria

Covered when ALL of the following are met:

Per-product dispensing limit: Dispensing of each listed product is allowed only up to the exact 'Dispensing Limit' specified (example formats: '30 Tablets Per 30 DAYS', '2 Syringes Per 28 DAYS', '1 Inhaler Per 30 DAYS').as stated per product

Brand/generic indicator (BG/B/G) on each entry governs allowable product types; limits vary by product and strength.

Product-specific dispensing limits

Covered when ALL of the following are met:

Product-specific limit — example: clonidine suspension (Onyda XR): Dispensing Limit = 120 mLs Per 30 DAYS; Brand Only (B)120 mLs/30 days

See product entry for exact strength and BG/B/G flag

Product-specific limit — example: clonidine ER tablet (Kapvay): Dispensing Limit = 120 Tablets Per 30 DAYS; Generic and Brand (BG)120 tabs/30 days

See product entry for exact strength and BG/B/G flag

Product-specific limit — clozapine formulations: Multiple clozapine entries list dispensing limits by formulation/strength (examples: 90–270 Tablets Per 30 DAYS depending on strength); BG/B/G varies by entry.varies by strength

Basic Dispensing Limits

Covered when ALL of the following are met:

Basic dispensing rule: A product is covered up to the specified Dispensing Limit (units per time period) and subject to the brand/generic indicator (BG/B/G).as listed per product

Some agents note cumulative quantity limits across formulations (for example, injectable insulin cumulative across formulations).

Dispensing limits

Covered when ALL of the following are met:

Product quantity limits per 30 days: Member coverage is limited to the listed dispensing limit for each named product (examples include: many injectable insulin solutions limited to 100 mLs Per 30 DAYS; Soliqua 100/33 limited to 6 Pens Per 30 DAYS; Afrezza cartridge quantities limited per configuration).per product per 30 days unless otherwise stated

Accessory items (pen needles, syringes) have cumulative QLs (e.g., 300 Units Per 30 DAYS); inhaled insulin cartridge limits vary by cartridge configuration—see product lines for exact counts.

Some plans may exclude coverage for specific drug categories or individual agents. The source list notes that certain categories (for example, medications for erectile dysfunction) may be excluded from coverage and that applicability can vary by member plan and state. Members and providers should confirm plan-specific exclusions or limitations using plan materials or by calling the number on the member ID card.

Quantities above the listed dispensing limits are not considered within the standard benefit and generally require additional review. Examples in the list show hard per-period caps (e.g., 2 Inhalers Per 30 DAYS for many albuterol inhalers); requests exceeding these listed limits may be subject to claim edits, denial, or a requirement for prior authorization or override at adjudication.

Any dispensing that exceeds a product's specified per-product limit is outside the allowance described for that product and may be denied or require additional review. For injectable products the document frequently lists cumulative limits (e.g., many injectable insulin formulations have a standard limit of 100 mLs Per 30 DAYS and pen-needle/syringe accessories a cumulative limit of 300 Units Per 30 DAYS), so fills above those per-product caps should trigger benefit-manager review.

Some product entries in the excerpt display placeholders or incomplete numeric fields (for example entries showing 'mL Per 30 DAYS' without a numeric value). These incomplete entries indicate the excerpt is partial and the exact numeric dispensing quantity should be confirmed in the complete policy or product-level listing prior to adjudication.

Within this excerpt there are no explicit clinical exclusions tied to individual diagnoses or indications; the content is limited to per-product dispensing limits and brand/generic coverage indicators. Clinical coverage decisions beyond the listed quantity limits are not specified in these chunks.

These chunks do not provide explicit clinical exclusion criteria. The policy text in this excerpt restricts coverage by product-specific dispensing limits and by brand/generic designation (BG/B/G) rather than by clinical exclusion language.

Multiple entries use the shorthand indicators BG, B, or G to denote brand/generic availability and coverage preference (BG = Brand and Generic; B = Brand Only; G = Generic Only). Where an entry is blank or not specified in the excerpt, the brand/generic status should be confirmed in the full policy or product listing.

Not specified in these chunks.

Coding, Examples, and Sample Limits

Basic Dispensing Limits - Selected CNS & ADHD Agentsmixed

Mydayis 12.5 mg	amphetamine-dextroamphetamine 3-bead cap er 24hr 12.5 mg (Mydayis) - Dispensing Limit = 30 Capsules Per 30 DAYS
Mydayis 25 mg	amphetamine-dextroamphetamine 3-bead cap er 24hr 25 mg (Mydayis) - Dispensing Limit = 30 Capsules Per 30 DAYS
Mydayis 37.5 mg	amphetamine-dextroamphetamine 3-bead cap er 24hr 37.5 mg (Mydayis) - Dispensing Limit = 30 Capsules Per 30 DAYS
Mydayis 50 mg	amphetamine-dextroamphetamine 3-bead cap er 24hr 50 mg (Mydayis) - Dispensing Limit = 30 Capsules Per 30 DAYS

Listed Insulin Products with Dispensing Limitsmixed

Insulin glargine soln pen-injector 100 unit/mL (Insulin Glargine Solostar)	Dispensing Limit = 100 mLs Per 30 DAYS, Quantity limit cumulative across injectable formulations
Insulin glargine soln pen-injector 300 unit/mL (Toujeo Solostar)	Dispensing Limit = 100 mLs Per 30 DAYS, Quantity limit cumulative across injectable formulations
Insulin glargine soln pen-injector 300 unit/mL (Toujeo Max Solostar)	Dispensing Limit = 100 mLs Per 30 DAYS, Quantity limit cumulative across injectable formulations
Insulin glargine soln pen-injector 300 unit/mL (Insulin Glargine Max Solostar)	Dispensing Limit = 100 mLs Per 30 DAYS, Quantity limit cumulative across injectable formulations
Insulin glargine-yfgn inj 100 unit/mL (Semglee)	Dispensing Limit = 100 mLs Per 30 DAYS, Quantity limit cumulative across injectable formulations

Inhaled Insulin (Afrezza) Cartridge Limitsmixed

Afrezza cartridges (various strengths)

Dispensing Limits vary by cartridge: e.g., 12 unit cartridge = 900 Cartridges Per 30 DAYS; 4 unit cartridge = 2520 Cartridges Per 30 DAYS; see product-specific entries

Pen Needles and Insulin Syringesmixed

Insulin pen needles (various gauges/lengths)	Dispensing Limit = 300 Units Per 30 DAYS, QL cumulative across all pen needles
Insulin syringes (U-100 and U-500, various sizes)	Dispensing Limit = 300 Units Per 30 DAYS, QL cumulative across all insulin syringes

Selected Drug Entriesmixed

Saphris 2.5 mg SL	asenapine maleate sublingual tab 2.5 mg - Dispensing Limit = 60 Tablets Per 30 DAYS
Saphris 10 mg SL	asenapine maleate sublingual tab 10 mg - Dispensing Limit = 60 Tablets Per 30 DAYS
Secuado patch	asenapine TD patch 24 hr 3.8 mg/24hr (Secuado) - Dispensing Limit = 30 Patches Per 30 DAYS; other Secuado strengths (5.7 mg, 7.6 mg) also listed at 30 patches per 30 days
Toujeo Max Solostar	insulin glargine soln pen-injector 300 unit/mL (2 unit dial) (Toujeo Max Solostar) - Dispensing Limit = 100 mLs Per 30 DAYS, Quantity limit cumulative across injectable formulations
Toujeo Solostar	insulin glargine soln pen-injector 300 unit/mL (1 unit dial) (Toujeo Solostar) - Dispensing Limit = 100 mLs Per 30 DAYS, Quantity limit cumulative across injectable formulations
Soliqua 100/33	insulin glargine-lixisenatide sol pen-injector 100-33 unit-mcg/mL (Soliqua 100/33) - Dispensing Limit = 6 Pens Per 30 DAYS (18 mLs = 6 syringes)

Topical Lidocaine Formulationsmixed

Lidocaine creams/gels/patches

Various lidocaine topical products - common Dispensing Limit = 120 Each Per 30 DAYS or specified gram/mL limits; cumulative across formulations

inv-20: Dispensing limit examples — e.g., 960 mLs per 30 days; 60 tablets per 30 days; 2 pens per 28 days; 1 inhaler per 30 days; 180 tablets per 30 days; 5 grams per 30 days

Example Dispensing Limits960 mLs per 30 days; 60 tablets per 30 days; 2 pens per 28 days; 1 inhaler per 30 days; 180 tablets per 30 days; 5 grams per 30 days

inv-21: Sample product limits — examples include 2 Pens Per 28 DAYS; 2 Syringes Per 28 DAYS; 2 Inhalers Per 30 DAYS; 30 Tablets Per 30 DAYS

Sample product limits2 Pens Per 28 DAYS; 2 Syringes Per 28 DAYS; 2 Inhalers Per 30 DAYS; 30 Tablets Per 30 DAYS

inv-22: Adderall tab 20 mg monthly limit — 90 Tablets Per 30 DAYS

Adderall 20 mg90 Tablets Per 30 DAYS

inv-23: Aripiprazole oral solution monthly limit — 900 mLs Per 30 DAYS

Aripiprazole oral solution900 mLs Per 30 DAYS

inv-24: Dispensing limits examples — e.g., 30 Tablets Per 30 DAYS; 60 Tablets Per 30 DAYS; 120 Tablets Per 30 DAYS; 60 Tablets Per 180 DAYS

Common tablet limits30 Tablets Per 30 DAYS; 60 Tablets Per 30 DAYS; 120 Tablets Per 30 DAYS; 60 Tablets Per 180 DAYS

inv-25: Weight percentile used for QL — CDC 90th percentile averaged to 112.5 kg

Weight percentile used for QLCDC 90th percentile averaged to 112.5 kg

inv-26: continuous glucose system receiver replacement — Receiver Per 365 DAYS

CGM receiver replacementReceiver Per 365 DAYS

inv-27: continuous glucose system sensor — 2-3 Sensors Per ~30 DAYS (varies by product)

CGM sensor2-3 Sensors Per ~30 DAYS (varies by product)

inv-28: droxidopa 300 mg dispensing limit — 180 Capsules Per 30 DAYS

Droxidopa 300 mg180 Capsules Per 30 DAYS

inv-29: dulaglutide (Trulicity) dispensing limits — Pens Per 28 DAYS (varies by strength; some strengths 4 pens per 28 days); fill limit of one GLP-1 agent and one strength per 28 days

Dulaglutide (Trulicity) limitsPens Per 28 DAYS (varies by strength); fill limit of one GLP-1 agent and one strength per 28 days

inv-30: dupilumab dispensing limits — 2 pens or 2 syringes per 28 DAYS (varies by presentation); some entries list 4 syringes per 28 DAYS

Dupilumab dispensing2 pens or 2 syringes per 28 DAYS (varies by presentation); some entries list 4 syringes per 28 DAYS

inv-31: econazole nitrate cream dispensing limit — 170 Grams Per 30 DAYS

Econazole nitrate cream170 Grams Per 30 DAYS

inv-32: Trikafta tablets dispensing limit — 84 Tablets Per 28 DAYS (tablet formulations) or 56 Packets Per 28 DAYS (granules)

Trikafta tablets/granules84 Tablets Per 28 DAYS (tablet formulations) or 56 Packets Per 28 DAYS (granules)

inv-33: Oral triptan monthly cap — Maximum 18 tablets per 30 days across all agents

Oral triptan capMaximum 18 tablets per 30 days across all agents

inv-34: Insulin per-30-day volume — 100 mLs Per 30 DAYS

Insulin per-30-day volume100 mLs Per 30 DAYS

inv-35: Standard dispensing limit — 100 mLs per 30 days for many injectable insulin formulations

Standard injectable insulin QL100 mLs per 30 days for many injectable insulin formulations

inv-36: Accessory dispensing limit — 300 units per 30 days (pen needles and syringes)

Accessory dispensing limit300 units per 30 days (pen needles and syringes)

inv-37: Insulin syringe cumulative limit — 300 Units Per 30 DAYS

Insulin syringe cumulative limit300 Units Per 30 DAYS

inv-38: Interferon beta (Betaseron) — 14 Vials Per 28 DAYS

Interferon beta (Betaseron)14 Vials Per 28 DAYS

inv-39: Rebif Rebidose — 12 Syringes Per 28 DAYS

Rebif Rebidose12 Syringes Per 28 DAYS

inv-40: Ixekizumab — 1 Syringe Per 28 DAYS

Ixekizumab1 Syringe Per 28 DAYS

inv-41: Latanoprost ophthalmic solution — 2.5 mLs Per 20 DAYS

Latanoprost solution2.5 mLs Per 20 DAYS

inv-42: QL cumulative across agents — e.g., lemborexant 30 Tablets Per 30 DAYS, QL cumulative across agents

QL cumulative across agents examplelemborexant 30 Tablets Per 30 DAYS, QL cumulative across agents

Per-Product Quantity Limit Table (Key-Value Entries)

inv-120: abacavir sulfate soln 20 mg/mL (Ziagen)

abacavir sulfate soln 20 mg/mL (Ziagen)Dispensing Limit = 960 mLs Per 30 DAYS.

reference chunkEntry appears in the policy’s Basic Dispensing Limits list for Ziagen solution.

brand/generic notationListed with BG/B/G coverage flags where applicable.

inv-121: abacavir sulfate tab 300 mg (Ziagen)

abacavir sulfate tab 300 mg (Ziagen)Dispensing Limit = 60 Tablets Per 30 DAYS.

listed in same chunkTab entry appears adjacent to solution entry in the policy list.

coverage flagAnnotated BG where specified in the list.

inv-122: abatacept subcutaneous soln auto-injector 125 mg/mL (Orencia Clickject)

abatacept subcutaneous auto-injector 125 mg/mL (Orencia Clickject)Dispensing Limit = 4 Syringes Per 28 DAYS.

also IV/pre-filled formsOther abatacept presentations have similar 4 syringes per 28 days or vial‑based limits listed.

brand designationOrencia entries indicated as B (brand) where specified.

inv-123: aclidinium br-formoterol inhaler (Duaklir Pressair)

aclidinium br–formoterol inhaler (Duaklir Pressair)Dispensing Limit = 1 Inhaler Per 30 DAYS.

applies to breath‑activated formulationEntry in policy lists inhaler per 30 days for the Duaklir presentation.

brand statusListed as Brand (B) where noted.

inv-124: adalimumab auto-injector kit (Humira pen)

adalimumab auto-injector kit (Humira pen)Dispensing Limit = 2 Pens Per 28 DAYS (kit variants may have separate kit limits).

adalimumab biosimilarsMultiple adalimumab biosimilars likewise listed with 2 Pens or 2 Syringes Per 28 DAYS in policy entries.

brand designationAdalimumab products are commonly annotated as B or BG depending on presentation.

inv-125: acyclovir buccal tab 50 mg (Sitavig)

acyclovir buccal tab 50 mg (Sitavig)Dispensing Limit = 2 Tablets Per 180 DAYS.

longer windowThis entry illustrates a 180‑day dispensing window for a low‑count product.

brand/generic noteListed with BG/B/G flags in the policy where applicable.

inv-126: adalimumab (multiple biosimilars and brands)

adalimumab (multiple biosimilars and brands)Standard dispensing limit = 2 Pens or 2 Syringes Per 28 DAYS (product‑specific presentations noted).

consistency across brandsPolicy lists numerous adalimumab brands/biosimilars with the same per‑period cap.

kit exceptionsSome starter or kit presentations may have alternate kit limits (e.g., Kit Per 180 DAYS).

inv-127: albuterol inhalers (selected HFA and Respiclick/Digihaler)

albuterol inhalers (selected HFA and Respiclick/Digihaler)Dispensing Limit = 2 Inhalers Per 30 DAYS (6 packages per 90 days noted).

nebulizer solutionsRelated nebulizer solution entries show vial and mL limits (e.g., 120 vials or 60 mLs per 30 days).

brand/generic indicatorAlbuterol inhaler entries marked BG where applicable.

inv-128: alprostadil injectable and urethral products (Caverject, Muse, Edex)

alprostadil injectable and urethral products (Caverject, Muse, Edex)Dispensing Limit = 8 Doses Per 30 DAYS for injections/pellets; kit presentations noted separately.

kit variantsSome alprostadil kits are listed as Kit Per 30 DAYS depending on presentation.

brand statusEntries show BG/B/G flags as specified.

inv-129: amifampridine phosphate (Firdapse) 10 mg

amifampridine phosphate (Firdapse) 10 mgDispensing Limit = 300 Tablets Per 30 DAYS.

brand designationFirdapse listed as Brand (B) in the excerpt.

high-count oral specialtyExample of higher monthly tablet cap for specialized oral neurologic agent.

inv-130: amikacin liposome inhalation (Arikayce) 590 mg/8.4 ml

amikacin liposome inhalation (Arikayce) 590 mg/8.4 mLDispensing Limit = 28 Vials Per 28 DAYS.

vial‑based inhaled antibioticPolicy lists vial counts per 28‑day window for Arikayce.

brand flagArikayce entry annotated as B in the document.

inv-131: afatinib (Gilotrif) tablets

afatinib (Gilotrif) tabletsDispensing Limit = 30 Tablets Per 30 DAYS.

oncology oral pack examplesOther targeted oral oncology agents include similar per‑period tablet caps in the list.

brand designationGilotrif entries show BG/B flags where noted.

inv-132: Adzenys XR-ODT 3.1 mg

Adzenys XR‑ODT 3.1 mgDispensing Limit = 60 Tablets Per 30 DAYS.

Adzenys XR‑ODT 6.3 mgDispensing Limit = 60 Tablets Per 30 DAYS.

ODT dosing patternsMultiple ODT strengths have specified 30‑ or 60‑tablet per‑month limits.

inv-133: Adzenys XR-ODT 6.3 mg

Adzenys XR‑ODT 6.3 mgDispensing Limit = 60 Tablets Per 30 DAYS.

strength‑specific limitsODT strengths commonly have either 30 or 60 tablets per 30 days depending on mg.

coverage flagEntries include BG/B/G where applicable.

inv-134: Mydayis (various strengths)

Mydayis (various strengths)Dispensing Limit = 30 Capsules Per 30 DAYS (per listed strengths).

stimulant capsule exampleIllustrates typical 30‑day capsule cap for extended‑release stimulant formulations.

brand/generic noteEntries indicate BG where applicable.

inv-135: Adderall tablets 20 mg

Adderall tablets 20 mgDispensing Limit = 90 Tablets Per 30 DAYS.

other Adderall strengthsOther tablet strengths show limits of 60–90 Tablets Per 30 DAYS depending on strength.

BG designationAdderall entries marked BG where indicated.

inv-136: Kineret 100 mg/0.67 mL

Kineret 100 mg/0.67 mLDispensing Limit = 28 Syringes Per 28 DAYS.

anakinra prefilled syringesListed syringe count consistent across the Kineret presentations in the policy.

brand flagEntry annotated as B where specified.

inv-137: Aripiprazole oral solution

Aripiprazole oral solutionDispensing Limit = 900 mLs Per 30 DAYS.

supports oral solution entryMatches policy listing for aripiprazole oral solution monthly cap.

related formulation limitsOther aripiprazole formulations have their own tablet/film limits listed nearby.

inv-138: Scemblix 40 mg

Scemblix 40 mgDispensing Limit = 240 Tablets Per 30 DAYS (per listed strength).

strength variabilityAsciminib entries include multiple strength‑specific tablet caps (60–240 per 30 days).

brand designationScemblix entries listed as B where specified.

inv-139: aripiprazole tab 30 mg with sensor; strips & starter pak (Abilify Mycite Starter pod Kit)

Aripiprazole tab 30 mg with sensor (Mycite Starter Kit)Dispensing Limit = 30 Tablets Per 30 DAYS for the starter pod kit.

kit/maintenance distinctionsPolicy distinguishes starter kits versus maintenance kits with similar per‑period tablet limits.

brand flagMycite kit entries annotated as Brand (B) in the list.

inv-140: asciminib hcl tab 100 mg (Scemblix)

asciminib hcl tab 100 mg (Scemblix)Dispensing Limit = 120 Tablets Per 30 DAYS.

other strength limitsAsciminib 20 mg and 40 mg listed with 60 and 240 tablets per 30 days respectively.

brand designationScemblix entries are marked B in the policy list.

inv-141: asenapine maleate sl tab 10 mg (Saphris)

asenapine maleate SL tab 10 mg (Saphris)Dispensing Limit = 60 Tablets Per 30 DAYS.

patch alternativeSecuado transdermal patches listed separately with 30 patches per 30 days.

brand/generic noteEntries include BG flags as specified.

inv-142: aspirin-omeprazole tab delayed release 325-40 mg (Yosprala)

aspirin‑omeprazole tab delayed release 325‑40 mg (Yosprala)Dispensing Limit = 30 Tablets Per 30 DAYS.

81‑40 mg packAlso listed with 30 Tablets Per 30 DAYS for the 81‑40 mg formulation.

brand designationEntries annotated as B where applicable.

inv-143: atazanavir sulfate oral powder packet 50 mg (Reyataz)

atazanavir sulfate oral powder packet 50 mg (Reyataz)Dispensing Limit = 240 Packets Per 30 DAYS (30 packets = 1 box).

tablet/capsule entriesOther Reyataz capsule strengths listed with 30–60 tablets/capsules per 30 days.

brand statusPacket formulation annotated as B (brand) in the policy.

inv-144: atogepant tab 30 mg (Qulipta)

atogepant tab 30 mg (Qulipta)Dispensing Limit = 30 Tablets Per 30 DAYS.

other atogepant strengths10 mg and 60 mg strengths also listed with 30 tablets per 30 days.

brand/generic noteEntries show BG/B/G flags as specified.

inv-145: avacopan cap 10 mg (Tavneos)

avacopan cap 10 mg (Tavneos)Dispensing Limit = 180 Capsules Per 30 DAYS.

high capsule countExample of a large monthly capsule limit for specialty oral agent.

brand designationListed as B in the policy where applicable.

inv-146: avapritinib tab 100 mg (Ayvakit)

avapritinib tab 100 mg (Ayvakit)Dispensing Limit = 30 Tablets Per 30 DAYS.

other strengthsMultiple Ayvakit strengths listed with the same 30‑tablet per‑month limit.

brand flagEntries annotated as B where specified.

inv-147: belimumab subcutaneous solution auto-injector 200 mg/mL (Benlysta)

belimumab subcutaneous auto-injector 200 mg/mL (Benlysta)Dispensing Limit = 4 Syringes Per 28 DAYS.

prefilled syringe presentationPrefilled syringe presentations also listed with the same 4 syringes per 28‑day cap.

brand designationBenlysta entries shown as B in the list.

inv-148: bimekizumab-bkzx subcutaneous soln auto-injector 160 mg/mL (Bimzelx)

bimekizumab‑bkzx auto‑injector 160 mg/mL (Bimzelx)Dispensing Limit = 2 Pens Per 56 DAYS (other presentations list 1 pen per 28 days or 2 syringes per 56 days).

presentation‑dependent limitsPolicy lists pen vs syringe counts with differing windows (28 vs 56 days) per presentation.

brand flagBimzelx entries annotated as B where applicable.

inv-149: bremelanotide acet subcutaneous soln auto-inj 1.75 mg/0.3 mL (Vyleesi)

bremelanotide (Vyleesi)Dispensing Limit = 8 Pens Per 30 DAYS (allows for 8 doses per month).

on‑demand dosing contextVyleesi is listed with a monthly pen/dose cap reflecting on‑demand dosing limits.

brand designationVyleesi entries listed as B in the policy.

inv-150: baloxavir marboxil tab therapy pack 1 x 40 mg (Xofluza)

baloxavir marboxil therapy pack (Xofluza)Dispensing Limit = 2 Tablets Per 120 DAYS for therapy packs.

therapy pack windowExample of a multi‑month limited therapy pack dispensing interval.

brand flagXofluza entries annotated as B where applicable.

Actions, Prior Authorization & Claim Handling

Prior Authorization

Dispensing limits — check prior authorization separately

Dispensing limits on this list are operational limits of the pharmacy benefit and do not by themselves convey clinical approval. Providers must verify prior authorization (PA) requirements separately — many high-cost, specialty, weight‑based, or brand‑only products on the list may require PA before coverage will be approved.

Check prior authorization rules separately for any product exceeding routine dispensing limits, specialty agents, weight‑based injectables, and brand‑only items.
When a claim exceeds the listed dispensing limit a prior authorization or medical exception request may be required; do not assume override at point of sale.
High‑cost specialty agents and weight‑based products (e.g., antihemophilic factors, coagulation factors, C1 esterase inhibitors, fertility injectables, and certain biologics) frequently require PA and clinical documentation tied to patient weight, dosing frequency, or special clinical criteria.

Prior Authorization

Prior authorization for specialty/weight‑based products

For specialty and weight‑based injectable products the dispensing limit shown is often a reference (e.g., “dependent on patient weight and number of doses”) rather than an automatic approval. PA is typically required to authorize quantities higher than standard per‑period limits and to document the clinical rationale.

Document patient weight, dose per administration, number of administrations per period, and clinical diagnosis when requesting quantities for weight‑dependent agents.
Refer to the Special Clinical Criteria Table where indicated (e.g., Haegarda) to support PA and quantity calculations.

Prior Authorization

Prior authorization when quantity exceeds listed limit

When a requested quantity exceeds the listed dispensing limit the pharmacy claim is at risk for denial or a quantity‑limit override; prior authorization or an exception must be obtained to avoid claim denial or member financial responsibility.

If prescribing beyond the listed limit, obtain PA before dispensing or inform the member they may be financially responsible for the excess.
Pharmacies should suspend or reject claims that exceed limits and follow payer override/PA workflows rather than dispense without coverage.
PA requests should include dosing schedule, justification for increased quantity, and any supporting clinical records.

Prior Authorization

Prior authorization for high‑limit specialty agents

Certain high‑limit specialty agents have explicit per‑period caps. Requests approaching or exceeding those caps commonly trigger PA requirements; obtain authorization early to prevent disruption of therapy.

Anticipate PA for fertility, coagulation, enzyme replacement, and other specialty injectable therapies with per‑month or per‑cycle vials/pens limits.
Use the stated calculation method (e.g., CDC 90th percentile weight assumptions) and attach calculation rationale when requesting exceptions.

Prior Authorization

Prior authorization may be required for weight‑based injectables

Weight‑based injectables (e.g., factor VIIa, factor VIII/IX, other coagulation factors) list limits ‘dependent on patient weight and number of doses.’ Prior authorization and weight‑based dosing documentation are often required to justify dispensed amounts.

Include patient weight, prescribed IU/kg dose, frequency, and anticipated number of doses per period with PA submissions.
Be prepared for retrospective adjustment or denial if weight‑based dosing is not supported in the medical record.

Step Therapy

Fill limits for GLP‑1 agents

Class‑level fill limits are applied to some therapeutic classes (notably GLP‑1 agents). The policy may restrict fills to one agent and one strength per fill period — requests for multiple GLP‑1 agents or additional strengths will likely be blocked or require PA.

For GLP‑1 agents (e.g., dulaglutide, liraglutide) the fill limit is typically one agent and one strength per 28 days; verify plan‑specific implementation.
If a prescriber intends concurrent or alternate GLP‑1 therapy, submit a PA with clinical rationale and prior treatment history.

Billing Rule

Per‑product dispensing limits imply benefit controls

Dispensing limits imply benefit controls and utilization management. Brand‑only designations, cumulative limits across agents or GPI groups, and per‑timeframe units (tablets, pens, syringes, mLs, vials) should be treated as enforceable limits that can trigger denials without PA.

Claims must match the listed units and timeframes (e.g., Tablets Per 30 DAYS, Syringes Per 28 DAYS, mLs Per 30 DAYS).
Cumulative limits (e.g., insulin mL limits across injectable formulations or QL cumulative across agents) are enforced at group or GPI level — check cumulative calculations before dispensing.
Brand‑only products may require PA when a generic alternative exists or when plan excludes non‑preferred brands.

Prior Authorization

Brand‑only products may need PA

Brand‑only products and items designated as non‑substitutable are frequently subject to PA or additional review. When a brand‑only flag is present verify whether the plan allows brand coverage or requires prior fail‑over and documentation.

If a brand‑only product is prescribed, confirm member’s benefit design and obtain PA if the plan restricts brand coverage.
Provide documentation of medical necessity for brand when a generic or biosimilar is available but not appropriate.

Denial Risk

Over‑quantity claims and quantity‑limit denials

Claims that exceed the stated dispensing limits are commonly denied or held for review. Pharmacies and providers should follow payer procedures for override, PA submission, or notifying members of potential out‑of‑pocket liability.

Do not dispense without verified coverage if the prescribed quantity exceeds the limit; member may be liable for the excess cost.
Submit PA or exception requests with full clinical justification to avoid retrospective denials and member billing.

Documentation Required

Quantity limit enforcement & documentation

Quantity limits are enforced as per the units/timeframe shown. Exceeding these limits may cause claim edits to reject at point‑of‑sale; an authorized PA is required to process higher quantities.

Verify days’ supply and quantity on the prescription match the listed dispensing limit to reduce rejects.
If a higher quantity is clinically necessary, submit PA prior to dispense and include dosing schedule and anticipated refill timing.

Documentation Required

Weight‑based quantity mismatch — documentation required

Weight‑based quantity mismatches (requests that do not align with expected weight‑based dosing) may be denied or adjusted. For coagulation factors and related biologics, include weight and dosing calculations when submitting claims or PA requests.

Attach calculation showing IU/kg dosing, patient weight, number of doses, and resulting total units or mLs for the PA review.
Anticipate dose rounding rules (e.g., rounded to nearest even dose) used in QL calculations and document any clinical reason for deviation.

Documentation Required

Required prescription details & quantity/days’ supply documentation

Claims and PA submissions must include prescription specifics — drug name (including strength and formulation), quantity, days’ supply, and dosing schedule — to align with the dispensing limit rules and permit accurate adjudication.

Prescriptions should specify strength, formulation (pen, syringe, vial), and intended days’ supply to match listed dispensing limits.
Pharmacies should submit claims reflecting the same units/timeframe format used in the limit (e.g., mLs Per 30 DAYS, Syringes Per 28 DAYS).

Documentation Required

Reference to Special Clinical Criteria

Special Clinical Criteria and other referenced guidance underpin some dispensing calculations (for example, Haegarda and C1 esterase inhibitor dosing). Review and include any applicable Special Clinical Criteria when submitting PA or exception requests.

Use the Special Clinical Criteria Table for calculating QLs where indicated and attach the calculation to the PA request.
Ensure the PA references the exact clinical criterion used (e.g., CDC 90th percentile weight assumptions) to support the requested quantity.

Billing Rule

Cumulative agent checks & cumulative limits

Where inventory entries note cumulative checks (e.g., ‘QL cumulative across agents’ or cumulative at GPI), claims adjudication will consider previous fills across the class or GPI — verify cumulative quantities before submitting additional fills.

Review prior fills for the same agent class or GPI to avoid exceeding cumulative limits.
When requesting an exception, provide a timeline of prior therapy and explain the clinical need for additional quantity.

Step Therapy

Step therapy & step/fill limits — verify plan rules

Some products have therapy class or agent‑level step/ fill rules (e.g., GLP‑1 fill limits). While explicit step therapy algorithms may not be listed here, providers should check plan step therapy requirements and submit PA where step rules or cross‑agent fill limits apply.

Confirm applicable step therapy requirements for specific agents before prescribing (plans may require trial of preferred agents).
If step therapy is present, document prior treatments and response to support PA for non‑preferred or second‑line agents.

Requirement	Notes
Fill limit of one GLP-1 agent and one strength per fill period	Example: liraglutide (Victoza) entry includes 'Fill limit of one GLP-1 agent and one strength per.' — the excerpt indicates a class-level restriction (e.g., one GLP‑1 agent and one strength per 28/30-day fill window) that must be enforced at point of dispense; the sentence in the source is incomplete in the excerpt but documents the intended single‑agent/strength fill restriction.
Coverage action when exceeded	Exceeding the one‑agent/one‑strength fill limit likely requires prior authorization or will be subject to quantity‑limit edits at claims adjudication.

OpenPayer

Basic Dispensing Limits (Pharmacy Quantity/Dispensing Limits)

Coverage and Dispensing Limit Criteria

Coding, Examples, and Sample Limits

Per-Product Quantity Limit Table (Key-Value Entries)

Actions, Prior Authorization & Claim Handling

Key Terms and Notation

Step Therapy and Class-Level Limits

Site-of-Care and Infusion Considerations

Background and Purpose