Blue Cross Blue Shield NM dispensing limits

Quantity Limits — Per-Product Entries

abacavir sulfate tab 300 mg

Dispensing limit60 Tablets per 30 DAYS

Productabacavir sulfate tab 300 mg (Ziagen)

SourcingBG (Brand and Generic allowed)

abaloparatide pen-injector (Tymlos)

Dispensing limit1.56 mLs (1 injection) per 30 DAYS

Productabaloparatide subcutaneous pen-injector 3120 mcg/1.56 mL (Tymlos)

SourcingB (Brand only)

abatacept (Orencia) prefilled syringe/auto-injector

Dispensing limit4 Syringes per 28 DAYS

Productabatacept subcutaneous solution prefilled syringe/auto-injector (Orencia)

SourcingB (Brand only)

abemaciclib tabs

Dispensing limit60 Tablets per 30 DAYS

Productabemaciclib tablets (Verzenio) — multiple strengths (50/100/150/200 mg)

SourcingB (Brand) — BG noted for some strengths

acyclovir buccal tab (Sitavig)

Dispensing limit2 Tablets per 180 DAYS

Productacyclovir buccal tablet 50 mg (Sitavig)

SourcingB (Brand only)

adalimumab auto-injector / prefilled syringe (grouped)

Common dispensing limit2 Pens or Syringes per 28 DAYS (varies by presentation)

Product groupadalimumab auto-injectors / prefilled syringes (Humira and biosimilars)

Starter kitsSome starter kits limited to 1 Kit per 180 DAYS

specific adalimumab biosimilars/presentations — pen/syringe limits

Per-product pen/syringe limit2 Pens or Syringes per 28 DAYS

ExamplesAmjevita (adalimumab-atto) 20/40 mg — 2 syringes per 28 DAYS; Hadlima Pushtouch 40 mg — 2 pens per 28 DAYS

SourcingB (Brand only) for listed biosimilars/presentations

adapalene pads 0.1%

Dispensing limit28 Pads per 28 DAYS

Productadapalene pads 0.1%

SourcingB (Brand)

afatinib dimaleate tablets (Gilotrif)

Dispensing limit30 Tablets per 30 DAYS

Productafatinib dimaleate tablets 20/30/40 mg (Gilotrif)

SourcingB (Brand only)

albuterol inhalers

Dispensing limit (inhalers)2 Inhalers per 30 DAYS

Productalbuterol sulfate inhalers (various HFA/brands)

SourcingBG (Brand & Generic) depending on SKU

albuterol solution for nebulizer

Dispensing limit120 Vials per 30 DAYS (examples include nebulizer solutions)

Productalbuterol sulfate solution for nebulizer

SourcingBG (Brand & Generic)

albuterol-budesonide inhalation aerosol (Airsupra)

Dispensing limit3 Inhalers per 30 DAYS

Productalbuterol-budesonide inhalation aerosol (Airsupra)

SourcingB (Brand only)

alirocumab auto-injector (Praluent)

Dispensing limit2 Pens per 28 DAYS

Productalirocumab auto-injector (Praluent) 150 mg/ml & 75 mg/ml

SourcingB (Brand only)

almotriptan — oral triptan cumulative rule

Cumulative oral triptan limitMaximum 18 tablets per 30 DAYS across all oral triptans

Product examplealmotriptan malate 6.25 mg & 12.5 mg — 18 Tablets per 30 DAYS

SourcingG (Generic) for almotriptan

Remaining per-product entries (summary)

Many remaining per-product limitsSee policy lines for each product; examples include topical, oral, injectable and device-specific limits (30-day, 28-day, 84-day, 180-day or annual windows)

Representative examplesamcinonide 100 g/30 days; amifampridine 300 tablets/30 days; alectinib 240 capsules/30 days; insulin device and supply limits

Sourcing flagsB / BG / G indicated per product line

Coding and Relevant Code Tables

Continuous glucose monitoring receiversmixedCovered

Dexcom G6 receiver	Dexcom g6 receiver
Dexcom G7 receiver	Dexcom g7 receiver
FreeStyle Libre 14 day reader	Freestyle libre 14 day/re
FreeStyle Libre 2 reader	Freestyle libre 2/reader/
FreeStyle Libre 3 reader	Freestyle libre 3/ reader/
FreeStyle Libre reader (generic)	Freestyle libre/reader/fl

Continuous glucose monitoring transmitters and sensorsmixedCovered

Dexcom G6 sensor	Dexcom g6 sensor
Dexcom G7 sensor	Dexcom g7 sensor
FreeStyle Libre 3 sensor	Freestyle libre 3/sensor/
FreeStyle Libre 2 sensor	Freestyle libre 2/sensor/
FreeStyle Libre 14 day sensor	Freestyle libre 14 day/se

Fertility agentsmixedCovered

follitropin alfa 1050 IU vial	Follitropin alfa for inj 1050 unit (Gonal-F)
follitropin alfa 450 IU vial	Follitropin alfa for inj 450 unit (Gonal-F)
menotropins 75 unit vial	Menotropins for subcutaneous inj 75 unit (Menopur)

Neurologic / neuropathic agentsmixedCovered

gabapentin once-daily 300 mg	Gabapentin (once-daily) tab 300 mg (Gralise)
gabapentin once-daily 450 mg	Gabapentin (once-daily) tab 450 mg (Gralise)
gabapentin once-daily 600 mg	Gabapentin (once-daily) tab 600 mg (Gralise)
gabapentin once-daily 750 mg	Gabapentin (once-daily) tab 750 mg (Gralise)
gabapentin once-daily 900 mg	Gabapentin (once-daily) tab 900 mg (Gralise)
gabapentin enacarbil ER 300 mg	Gabapentin enacarbil tab er 300 mg (Horizant)
gabapentin enacarbil ER 600 mg	Gabapentin enacarbil tab er 600 mg (Horizant)

Opioid agentsmixedCovered

hydrocodone bitartrate ER 10 mg cap	hydrocodone bitartrate cap er 12hr 10 mg
hydrocodone bitartrate ER 15 mg cap	hydrocodone bitartrate cap er 12hr 15 mg
hydrocodone bitartrate ER 20 mg cap	hydrocodone bitartrate cap er 12hr 20 mg
hydrocodone bitartrate ER 30 mg cap	hydrocodone bitartrate cap er 12hr 30 mg
hydrocodone bitartrate ER 40 mg cap	hydrocodone bitartrate cap er 12hr 40 mg
hydrocodone bitartrate ER 50 mg cap	hydrocodone bitartrate cap er 12hr 50 mg
hydrocodone bitartrate ER tab 24hr deter 100 mg	hydrocodone bitartrate tab er 24hr deter 100 mg (Hysingla Er)
hydrocodone bitartrate ER tab 24hr deter 120 mg	hydrocodone bitartrate tab er 24hr deter 120 mg (Hysingla Er)

Insulin products and related devicesmixedCovered

Humalog Mix 75/25 Kwikpen 100 U/ml	insulin lispro prot & lispro sus pen-inj 100 unit/ml (75-25)
Humalog Mix 50/50 100 U/ml	insulin lispro protamine & lispro inj 100 unit/ml (50-50)
Afrezza inhalation cartridges	insulin regular (human) inh powd / inhalation powder (Afrezza) various strengths
Humulin R U-500 500 U/ml	insulin regular (human) inj 500 unit/ml (Humulin R U-500)
Insulin pen needles	insulin pen needle various gauges/lengths — 29g,30g,31g,32g multiple lengths; QL cumulative across pen needles

Provider Actions, Prior Authorization & Billing Notes

Note

Dispensing-limit coverage effect

Coverage is limited to the dispensing quantity shown for each drug; if a prescriber orders a greater quantity than the listed dispensing limit, coverage will be limited to the stated amount and the member is responsible for costs above that amount.

Prior Authorization

PA may be required when exceeding dispensing limits

For certain specialty biologics and other limited items (examples: many adalimumab presentations, evolocumab, benralizumab), requests for quantities above the stated per-period limits may require prior authorization or exception review.

Prior Authorization

PA for exceeding pack frequency

Starter packs and products with longer pack intervals (for example, apixaban starter pack or apremilast starter/initiation packs) that are limited per 180 days or similar periods may require prior authorization if dispensed more frequently than the listed pack frequency.

Note

Prior authorization rules not specified here

This excerpt lists dispensing limits and brand/generic designations but does not set out comprehensive prior authorization procedures or explicit PA criteria in these chunks.

Documentation Required

Adhere to product-specific limits

Adhere to product-specific annual or multi-month limits for high-cost items (examples: caplacizumab limited to 58 kits per 365 days; continuous glucose system receivers limited to 1 per 365 days).

Prior Authorization

Dispensing limit enforcement may trigger PA

When the requested quantity exceeds the listed per-period dispensing limit for a medication or device, prior authorization or override may be required per payer processes.

Note

Injectable GLP-1: one agent/strength per 28 days

Injectable GLP-1 agents are limited to one injectable agent and one strength per 28 days (examples: dulaglutide, exenatide); dispensing more than the single agent/strength within 28 days is outside the stated fill limit.

Dulaglutide: 4 pens per 28 days with fill limit of one agent/one strength per 28 days
Exenatide examples reference same single-agent/strength 28-day fill rule

Prior Authorization

PA required for quantities above listed limits

Dispensing quantities above the stated per-period limits (e.g., items with 28-, 30-, 90-, or 365-day windows) generally require prior authorization according to payer rules.

Prior Authorization

Prior authorization when fills exceed window rules

If fills would exceed fill-window rules (for example, refill packs or starter kits with specified windows), prior authorization may be necessary to dispense beyond the allowed fill window.

Note

Prior Authorization

PA for durable/one-time kits with long intervals

For products with long interval limits (for example, insulin infusion pump starter kits limited to 1 kit per 720 days), prior authorization or utilization review may be required for additional kits.

Prior Authorization

PA required for quantities above dispensing limits (insulin examples)

Coverage is limited to the listed dispensing quantities; items such as insulin pens/solutions (100 mLs per 30 days examples) are enforced at the listed limit and prior authorization may be required for amounts above the limit.

Insulins commonly limited to 100 mLs per 30 days
Afrezza cartridge limits shown per 30 days

Prior Authorization

PA for over-limit dispensing of specialty agents

Some specialty oral agents with low monthly limits (example: ixazomib capped at 3 capsules per 28 days) will require prior authorization for dispensing beyond that low monthly limit.

Prior Authorization

PA and refill-window interactions (example: liraglutide)

Fill limits and refill-window language for select products (example: liraglutide pen-injector, limit = 3 pens per 30 days and single-agent/strength rules) may interact with benefit rules; exceedances may need prior authorization.

Note

Coverage governed by product dispensing limits

Coverage in this excerpt is governed by the fixed dispensing limits per product/strength; the document does not provide broader PA criteria in these chunks.

Step Therapy

Step therapy not specified

No step therapy requirements are specified in the provided excerpt; the section lists dispensing limits but does not define step therapy sequences.

Note

Verify member plan limits via ID card/plan materials

Members should verify plan-specific dispensing limits or exclusions by consulting plan materials or calling the number on the back of their ID card.

Documentation Required

Document cumulative quantities across agents

For products with cumulative or cross-agent limits (example: oral triptans capped at 18 tablets per 30 days across all agents), document total tablets across agents to demonstrate compliance.

Oral triptan cumulative maximum = 18 tablets per 30 days across all oral triptans

Billing Rule

Submit claims matching per-product dispensing limits

Pharmacies must submit claims reflecting the per-product dispensing limit (e.g., '30 Tablets Per 30 DAYS' or '4 Syringes Per 28 DAYS'); claims should match the listed quantity to avoid adjudication issues.

Documentation Required

Special QL calculation and documentation (C1 esterase inhibitors)

Certain products require special quantity-limit calculations and supporting documentation (example: C1 esterase inhibitors where vial counts use CDC 90th percentile weight assumptions).

Example calculation: Cinryze 1,000 IU every 3 days -> 10,000 IU/30 days -> 20 vials of 500 IU

Billing Rule

Dispense within listed limits and indicate BG/B/G

Pharmacists must dispense quantities not exceeding each product's listed limit and must indicate the BG/B/G brand/generic designation when submitting the claim.

Documentation Required

Required claim-level documentation: NDC, quantity, date

Pharmacy claims should document the NDC/medication, quantity dispensed, and date of dispensing to enable enforcement of the specified dispensing limits at adjudication.

Documentation Required

Adhere to fill limits and refill windows

Prescriptions must conform to the product-specific fill limits and any refill-window restrictions (for example, injectable GLP-1 limits and refill windows) to avoid denials or requirement for prior authorization.

Documentation Required

Align quantity with days supply on prescriptions

Ensure the prescribed quantity and days supply align with the dispensing limit (for example, 30 tablets per 30 days) so claims reflect consistent quantity-to-days-supply relationships.

Billing Rule

Claims must reflect formulation/unit consistent with limit

Claims should reflect the formulation/unit billed (inhaler, tablet, syringe, pen, cartridge, mL) consistent with the product's listed dispensing limit.

Billing Rule

Pharmacy claim detail must match listed dispensing limits

Pharmacy claims must show product, formulation, and quantity consistent with the per-period dispensing limits for each listed NDC/brand/formulation to support adjudication.

Documentation Required

Follow additional dispensing instructions (e.g., GLP-1 fill limits)

Some entries include explicit additional dispensing instructions (for example: 'fill limit of one injectable GLP-1 agent and one strength per 28 days'); follow and document such instructions on the claim or PA request when applicable.

Billing Rule

Dispense at or below each product's specified quantity/frequency

Dispense no more than the specified quantity and frequency for each listed product/strength (e.g., 3 pens per 30 days for liraglutide; 4 syringes per 28 days for belimumab).

Denial Risk

Member financial responsibility for over-limit quantities

If a prescriber orders a greater quantity than the dispensing limit, the member may obtain the medication but will be responsible for the full cost of the amount beyond coverage.

Denial Risk

Denial risk when exceeding listed dispensing limits

Requests that exceed per-period dispensing limits (multiple examples across the list) may be denied at point of dispensing or require an override/prior authorization to be covered.

Example: many adalimumab presentations limited to 2 pens/syringes per 28 days
Oral triptan cumulative limits (18 per 30 days) may trigger denial if exceeded

Definitions and Flags

Dispensing Limit — definition

DefinitionDispensing Limit = maximum quantity of a covered medication BCBSNM will cover per prescription or within a specified time period

ImplicationIf prescribed amount exceeds the limit, member may obtain medication but will be responsible for cost beyond coverage

Examples'30 Tablets Per 30 DAYS', '4 Pens Per 28 DAYS'

BG / B / G coding

DefinitionBG / B / G flags indicate whether entry applies to Brand & Generic (BG), Brand only (B), or Generic only (G)

UsageEach product line shows its sourcing flag next to the dispensing limit

Exampleabacavir tab 300 mg — BG; Dexcom receivers — B

Dispensing Limit — alternate wording & note

Dispensing limit (alt wording)Maximum permitted quantity of a specific product to be dispensed within the specified time period (e.g., '30 Capsules Per 30 DAYS')

Cumulative categoriesCertain categories (insulin syringes/pen needles) use cumulative QL across SKUs — e.g., 300 per 30 days

Claim requirementPharmacy claims must reflect product, quantity, and days supply to enforce the limit

BG / B / G — flag meanings

Meaning of flagsB = Brand only; G = Generic only; BG = Brand and Generic allowed

LocationFlags are displayed alongside each product's dispensing limit in the list

ExampleMany entries indicate BG/B/G per line (see product rows)

QL cumulative across strengths

QL cumulative across strengthsA single cumulative quantity limit applies across multiple strengths of the same drug (claims for different strengths count toward one cap)

Examplesazithromycin 60 Tablets per 180 DAYS cumulative across strengths; topical steroid grams cumulative (100 g/30 days)

EnforcementPharmacy must sum quantities across strengths when adjudicating claims

QL calculation based on CDC 90th percentile

Special QL calculationFor certain weight-based products (C1 esterase inhibitors), QL calculated using CDC 90th percentile adult weight; example: 1,000 IU every 3 days -> 20 vials of 500 IU per 30 days

ProductsCinryze, Berinert, Haegarda, Ruconest — vial/kit limits specified

ReferenceSee Special Clinical Criteria Table for calculation details

B/BG/G designations (notation)

NotationB/BG/G designations are used across the product lists to indicate sourcing availability

How to readEach product line pairs the dispensing limit with its sourcing flag (e.g., '60 Tablets Per 30 DAYS; BG')

PurposeHelps pharmacies select allowable NDCs for coverage adjudication

BG / B / G individual flag definitions

BG definitionBG = Brand and Generic allowed

B definitionB = Brand only

G definitionG = Generic only

Fill limit for injectable GLP-1 agents

Injectable GLP-1 fill limit (definition)Restriction limiting number of injectable GLP-1 agents and strengths dispensed in a 28-day period — one agent and one strength per 28 days

Common numeric limitse.g., dulaglutide = 4 pens per 28 DAYS; liraglutide = 3 pens per 30 DAYS (fill-window rules apply)

Action for claimsClaims exceeding this constraint may require PA/override

Quantity limit cumulative across categories (insulin example)

Cumulative category exampleInsulin pen needles and syringes: 300 units cumulative per 30 DAYS

Insulin volume limitMost insulin pens/solutions limited to 100 mLs per 30 DAYS cumulative across injectable formulations

Claim notePharmacy must sum counts across all SKUs in the category when adjudicating

Cumulative quantity limit across category

Cumulative quantity limit (general)A single cumulative quantity limit applies across all listed items in a category (e.g., pen needles or syringes) — counts aggregate across SKUs

ExampleInsulin pen needles: 300 per 30 DAYS cumulative across all pen needle SKUs

PurposePrevents separate fills of different SKUs from exceeding policy limits

QL cumulative — insulin syringes

QL cumulative (insulin syringes)300 syringes per 30 DAYS cumulative across all insulin syringe formulations

EnforcementClaims for different syringe SKUs must be summed to the 300 cap

Example entriesMultiple insulin syringe SKUs listed with the 300/30 limit

BG / B / G flags indicating brand/generic availability

BG/B/G flag usageFlags indicate Brand/Generic availability: BG = Brand & Generic, B = Brand only, G = Generic only

PlacementFlags appear next to each product's dispensing limit in the list

PurposeGuides allowable NDC selection for claim adjudication

OpenPayer

Balanced Dispensing Limits (pharmacy quantity limits)

Coverage Criteria — Dispensing Limits

Quantity Limits — Per-Product Entries

Coding and Relevant Code Tables

Provider Actions, Prior Authorization & Billing Notes

Background and Rationale

Definitions and Flags

Revision History