Enhanced Dispensing Limits for Drugs
Defines quantity and time-based dispensing limits for specific branded drugs and generics for members of participating Blue Cross and Blue Shield plans; applies to pharmacy coverage and dispensing quantities per prescription/time period.
No material clinical or coverage changes in this revision.
Coverage and Dispensing Limits
Product-specific dispensing limits
Covered when the requested dispensing quantity does not exceed the product-specific limits listed below and the request matches the listed brand/generic designation. Requests exceeding these limits may require additional authorization or will be the member's financial responsibility per plan terms.
ALL of the following
- Coverage is subject to the product-specific dispensing limit (quantity and time window) shown for each listed product.
- Coverage is subject to the Brand/Generic designation shown for each product (BG = Brand or Generic, B = Brand only, G = Generic only).
- If a prescriber writes for a quantity greater than the dispensing limit, the member may obtain the additional quantity but will be responsible for costs beyond the covered limit; prior authorization may be required for overrides.
- Some products have additional fill restrictions (for example, cumulative limits across strengths, limits across product formulations, or limits on concurrent fills of medications within a class). These are noted on the individual product entries when applicable.
- Dispensing limits may vary by member plan, state regulation, or mail-service availability. Members should verify plan-specific coverage and limits using their plan materials or by contacting customer service.
- abacavir sulfate soln 20 mg/ml (Ziagen) — 960 mLs per 30 days; BG
- abacavir sulfate tab 300 mg (Ziagen) — 60 tablets per 30 days; BG
- abacavir sulfate-lamivudine tab 600-300 mg (Epzicom) — 30 tablets per 30 days; BG
- abacavir-dolutegravir-lamivudine tab 600-50-300 mg (Triumeq) — 30 tablets per 30 days; B
- abaloparatide subcutaneous soln pen-injector 3120 mcg/1.56ml (Tymlos) — 1.56 mLs per 30 days (1 injection); B
- abatacept for IV soln 250 mg (Orencia) — 4 vials per 28 days; B
- abemaciclib tab (Verzenio) 50–200 mg — 60 tablets per 30 days; B
- abiraterone acetate tab (Yonsa/Zytiga) — 60–120 tablets per 30 days depending on strength; B or BG as noted
- abrocitinib tab (Cibinqo) 50–200 mg — 30 tablets per 30 days; B
- acalabrutinib maleate tab 100 mg (Calquence) — 60 tablets per 30 days; B
- aclidinium bromide-containing inhalers (Duaklir Pressair, Tudorza Pressair) — 1 inhaler per 30 days; B
- adapting examples: azithromycin tabs — 60 tablets per 180 days cumulative across strengths; BG
- clozapine formulations — tablets and suspension have product-specific limits (e.g., 270 tablets per 30 days for some strengths; G or BG as noted).
- continuous glucose monitoring supplies (Dexcom, FreeStyle Libre) — sensors/transmitters/receivers have specific limits (e.g., 2 sensors per 28–30 days, 1 receiver per 365 days, 1 transmitter per 90 days); B
- dulaglutide auto-injector (Trulicity) — 4 pens per 28 days; fill limit of one GLP-1 agent and one strength per 28 days; B
- dupilumab (Dupixent) pens/syringes — product-specific pen/syringe limits per 28 days (e.g., 2 pens of 200 mg/1.14 mL or 4 pens of 300 mg/2 mL depending on formulation); B
- droxidopa caps (Northera) — up to 180–450 capsules per 30 days depending on strength; BG
- etanercept (Enbrel) — 4 syringes or pens per 28 days (varies by presentation); B
- selected oncology and specialty oral agents (e.g., dabrafenib, dacomitinib, danicopan, entrectinib, enzalutamide, etc.) — typical limits 30–90 dosage units per 28–30 days as listed per product; B
- hydrocodone ER formulations — example limits: 30–60 capsules per 30 days depending on product; B or BG as noted
- insulin products and injectable formulations — standard dispensing limits commonly set at 100 mLs per 30 days for many insulin solutions; some combination pens have specific pen-per-month or box limits and cumulative limits across injectable formulations; B
- GLP‑1 and other injectable diabetes/weight management combination products — specific pen or syringe limits and restrictions on concurrent fills (e.g., refill windows, one agent/strength per period) as noted per product.
- This list is illustrative; every product entry in the full policy includes the exact dispensing limit, time window, and BG/B/G designation. Coverage is determined by the exact product entry and the member’s plan benefits.
Product Listings and Coding / Limits
| continuous blood glucose system sensor - Freestyle libre 14 day sensor | Freestyle Libre 14 day sensor; Dispensing Limit = 2 Sensors Per 28 DAYS |
| continuous blood glucose system sensor - Freestyle Libre 2 sensor | Freestyle Libre 2 sensor; Dispensing Limit = 2 Sensors Per 28 DAYS |
| continuous blood glucose system sensor - Freestyle Libre 3 sensor | Freestyle Libre 3 sensor; Dispensing Limit = 2 Sensors Per 28 DAYS |
| continuous blood glucose system sensor - Freestyle Libre 2 plus sensor | Freestyle Libre 2 Plus sensor; Dispensing Limit = 2 Sensors Per 30 DAYS |
| continuous blood glucose system sensor - Freestyle Libre 3 plus sensor | Freestyle Libre 3 Plus sensor; Dispensing Limit = 2 Sensors Per 30 DAYS |
| continuous glucose system sensor - Dexcom G6 sensor | Dexcom G6 sensor; Dispensing Limit = 3 Sensors Per 30 DAYS |
| continuous glucose system sensor - Dexcom G7 sensor | Dexcom G7 sensor; Dispensing Limit = 3 Sensors Per 30 DAYS |
| continuous glucose system receiver - Dexcom G6 receiver | Dexcom G6 receiver; Dispensing Limit = 1 Receiver Per 365 DAYS |
| continuous glucose system receiver - Dexcom G7 receiver | Dexcom G7 receiver; Dispensing Limit = 1 Receiver Per 365 DAYS |
| continuous glucose system receiver - Freestyle Libre 14 day reader | Freestyle Libre 14 day reader; Dispensing Limit = 1 Receiver Per 365 DAYS |
| continuous glucose system receiver - Freestyle Libre 2 reader | Freestyle Libre 2 reader; Dispensing Limit = 1 Receiver Per 365 DAYS |
| continuous glucose system receiver - Freestyle Libre reader | Freestyle Libre reader; Dispensing Limit = 1 Receiver Per 365 DAYS |
| continuous glucose system transmitter - Dexcom G6 transmitter | Dexcom G6 transmitter; Dispensing Limit = 1 Transmitter Per 90 DAYS |
| continuous glucose system transmitter - Dexcom G7 transmitter | Dexcom G7 transmitter; Dispensing Limit = product-specific; see policy |
| insulin infusion disposable pump kit - Omnipod variants | Dispensing Limit = 1 Kit Per 720 DAYS |
| insulin infusion pump - device (Ilet pump) | Dispensing Limit = 1 Kit Per 720 DAYS |
| insulin infusion disposable reservoir/infus set kit | Dispensing Limit = 1 Kit Per 30 DAYS |
| insulin infusion pump supplies | Dispensing Limit = variable per product (see policy) |
| coagulation factor IX (recombinant) - Ixinity | Dispensing Limit = 1 mL Per 30 DAYS |
| coagulation factor IX (recombinant) - Rixubis | Dispensing Limit = 1 mL Per 30 DAYS |
| dabigatran etexilate (Pradaxa) pellet packs | Dispensing Limits vary by strength (60-120 Packets Per 30 DAYS) |
| clozapine formulations | Multiple forms with dispensing limits (tablets up to 270 per 30 days; suspension up to 540 mLs per 30 days) |
| doxepin hcl (Silenor) | Dispensing Limit = 30 Tablets Per 30 DAYS |
| doxepin hcl cream (Prudoxin/Zonalon) | Dispensing Limit = 45 Grams Per 180 DAYS |
| doxylamine-pyridoxine (Diclegis/Bonjesta) | Dispensing Limits = 60-120 Tablets Per 30 DAYS depending on product |
| drospirenone (Slynd) | Dispensing Limit = 28 Tablets Per 21 DAYS |
| drospirenone-estetrol (Nextstellis) | Dispensing Limit = 28 Tablets Per 21 DAYS |
| drospirenone-ethinyl estradiol (Yaz/Yasmin) | Dispensing Limit = 28 Tablets Per 21 DAYS |
| dulaglutide (Trulicity) pens | Dispensing Limit = 4 Pens Per 28 DAYS; Fill limit of one GLP-1 agent and one strength per 28 days |
| dupilumab (Dupixent) pens/syringes | Dispensing Limits vary by presentation (2-4 pens/syringes per 28 days) |
| duloxetine formulations | Dispensing Limits vary by formulation (capsules/tablets per 30 days) |
| duloxetine (Cymbalta/Drizalma) | Dispensing Limits vary by strength (60-180 Capsules Per 30 DAYS) |
| dupilumab - multiple strengths | Dispensing Limits = 2-4 Pens or Syringes Per 28 DAYS depending on strength |
| empagliflozin (Jardiance) | Dispensing Limit = 30 Tablets Per 30 DAYS |
| emtricitabine oral solution (Emtriva) | Dispensing Limit = 680 mLs Per 28 DAYS |
| en alapril oral solution (Epaned) | Dispensing Limit = 1200 mLs Per 30 DAYS |
| elexacaftor-tezacaftor-ivacaftor (Trikafta) | Dispensing Limits vary by formulation (28-day windows) |
| efavirenz-containing combos | Dispensing Limit = 30 Tablets Per 30 DAYS |
| elbasvir-grazoprevir (Zepatier) | Dispensing Limit = 30 Tablets Per 30 DAYS |
| eltrombopag (Promacta/Alvaiz) | Dispensing Limits vary by formulation (30-60 per 30 days) |
| elvitegravir-containing combos (Genvoya/Stribild) | Dispensing Limit = 30 Tablets Per 30 DAYS |
| encorafenib (Braftovi) | Dispensing Limit = 180 Capsules Per 30 DAYS |
| enfuvirtide (Fuzeon) | Dispensing Limit = 60 Vials Per 30 DAYS |
| insulin syringe (Monoject) | Dispensing Limit = 300 Syringes Per 30 DAYS; QL cumulative for all insulin syringes |
| insulin glargine (various presentations) | Dispensing Limit = 100 mLs Per 30 DAYS; QL cumulative across injectable formulations |
| insulin lispro (various presentations) | Dispensing Limit = 100 mLs Per 30 DAYS |
| insulin regular inhalation (Afrezza) | Dispensing Limits vary by cartridge strength (multiple high-volume limits per 30 DAYS) |
| insulin infusion pump supplies (Ilet) | Dispensing Limits = 10-20 Kits Per 30 DAYS depending on supply type |
| insulin infusion disposable pump reservoir/infus set kit (Twiist) | Dispensing Limit = 1 Kit Per 30 DAYS |
| 30-day volume threshold | Common 30-day volume threshold referenced in policy: 100 mLs |
| 30-day window example | Examples of per-window dispensing limits: 28/30/90/180 day windows |
| tablet limit example | Example tablet limit: 30 Tablets Per 30 DAYS |
| liquid dispensing example | Example liquid limit: 680 mLs Per 28 DAYS |
| oral solution example | Oral solution example: 1200 mLs Per 30 DAYS |
Prescriber / Pharmacy Actions and Authorization
Dispensing limits define covered quantity
Coverage applies only up to the product-specific dispensing quantity and time window shown for each listed drug (e.g., “abacavir sulfate tab 300 mg … Dispensing Limit = 60 Tablets Per 30 DAYS”).
Fixed quantity limits may trigger prior authorization
Many products are assigned fixed per-period dispensing limits (for example, adalimumab presentations are limited to 2 pens or 2 syringes per 28 days and common inhalers to 2 inhalers per 30 days); requests outside those limits may require prior authorization.
PA or denial possible if limits exceeded
When a claim exceeds a listed dispensing limit (quantity per the specified days), the request may trigger prior authorization or denial at adjudication.
PA for brand-only or over-limit requests
Brand-only products or requests conflicting with the BG/B/G flag (brand/generic designation) and/or exceeding the stated limit may require prior authorization.
Enforced dispensing limits at POS/adjudication
High-cost or limited-availability products have explicit per-period dispensing limits that are enforced at point of sale or during adjudication (examples include many biologics and specialty agents).
Prior authorization likely for over‑limit dispensing
Requests for quantities above the stated product limits are likely to require prior authorization per payer processes (claims exceeding numeric limits typically require an override or PA).
Quantity and fill‑limit examples (dulaglutide)
Examples of quantity and fill limits are stated explicitly (e.g., dulaglutide: 4 pens per 28 days with a fill limit of one injectable GLP‑1 agent and one strength per 28 days).
Product limits and brand/generic flags must be followed
Product entries include specific dispensing limits (e.g., “30 Tablets Per 30 DAYS”, “60 Tablets Per 30 DAYS”, “680 mLs Per 28 DAYS”) and the BG/B/G availability flag which must be followed.
Authorization via limits and fill windows (no general PA rules stated)
The policy controls access primarily via dispensing limits and refill-window restrictions; no separate, general step therapy algorithm is defined in this segment.
Per‑product dispensing limits imply PA when exceeded
Many listed drugs and formulations state explicit per-period dispensing limits (numerous examples across product listings); exceeding those quantities may prompt prior authorization or denial.
PA for specialty over‑limit dispensing
Specialty and limited-distribution drugs include explicit per-period dispensing limits (for example, Brexafemme 4 tablets per 90 days); requests exceeding these limits may require prior authorization.
Device/kit limits may require authorization
Durable devices and starter kits (for example, insulin infusion pump kits) are limited (e.g., 1 kit per 720 days) and may require prior authorization if requested more frequently.
PA for specialty quantities (ivacaftor example)
Certain high‑cost specialty drugs list per‑30‑day limits (e.g., ivacaftor: 60 packets/tablets per 30 days); dispensing beyond those quantities may prompt prior authorization.
Single‑unit per‑period enforcement (ixekizumab example)
Some biologic products are limited to one syringe/pen per 28 days (for example, ixekizumab), and these per‑period limits are enforced.
Step therapy not specified
No explicit step therapy requirements are specified in these chunks; the document provides dispensing limits and BG/B/G flags but does not define step‑therapy sequences.
Titration pack allowance for iloperidone
A titration pack allowance is specified for iloperidone: one titration pack per 180 days — use this as the permitted titration supply when documenting fills.
No step therapy rules listed
Overall, the policy does not establish step therapy requirements; it lists dispensing limits and product flags but no step‑therapy sequences are described.
Verify plan‑specific limitations
Members and providers should verify plan‑specific limitations or exclusions via plan materials or the phone number on the back of the member’s ID card because limits and availability may vary by plan/state.
Adhere to product‑specific dispensing limits on claims
Pharmacy claims must adhere to the product presentation and stated dispensing limit (for example, inhalers limited to 2 inhalers per 30 days for Proair/Proventil/Ventolin HFA).
Use listed limits and BG/B/G status for adjudication
Drug‑level dispensing limits (quantity and time window) and the BG/B/G formulary status are provided and must be used for claims adjudication and documentation.
Prescribe per listed limit and brand/generic flag
Prescriptions must conform to the listed dispensing limit and the brand/generic designation (BG/B/G) shown for that NDC/strength/formulation.
Align claim quantity with product days‑supply window
Pharmacy claims should reflect the specified dispensing quantity and matching days‑supply window for the product (for example, Freestyle Libre sensors: 2 sensors per 28 days).
Topical cumulative quantity must be documented
For certain topical agents a cumulative limit applies (e.g., 100 grams per 30 days across agents); documentation must support medical necessity when requesting exceedance.
Enforce strength/agent‑level dispensing limits on claims
Pharmacy claims must conform to product‑specific dispensing limits and may require strength/agent‑level enforcement (for example, fill limits for injectable GLP‑1 agents).
Ensure claims show compliant quantity and days‑supply
Claims must show a quantity at or below the product dispensing limit and the matching days‑supply window (e.g., 30‑day or 28‑day windows) to avoid adjustment or denial.
Match dispensed quantity to billing units
Dispensed quantities should align with billing units for vial/cartridge presentations (example: follitropin beta cartridges billed as 0.420 mL, 0.780 mL, 1.170 mL) — bill accordingly.
Indicate formulation and strength on the prescription
Prescriptions should indicate the formulation and strength consistent with the listed product name so the claim maps to the correct dispensing limit.
Document deviations from listed product limits
Prescriptions and documentation must follow listed product‑specific dispensing limits (examples: kit limits per 720 days, 30 pods per 30 days); provide supporting documentation for deviations.
Match prescriptions to product packaging
Prescriptions for products with kit or package limits should match the product packaging (for example, 1 carton = 12 syringes for Rebif Rebidose) when submitting claims.
Account for cumulative lidocaine limits across formulations
When dispensing topical lidocaine formulations, document cumulative quantities across formulations because limits apply cumulatively across products.
Member cost responsibility for over‑limit prescriptions
If the prescriber writes quantity greater than the dispensing limit, the member may still obtain the medication but will be responsible for the full cost of the portion beyond coverage limits.
Exceeding listed limits may cause denial or override
Dispensing beyond listed quantity limits (for example, >2 pens/syringes per 28 days for many adalimumab presentations) may trigger denial or require an override/authorization.
Claims may be denied if quantity limits are exceeded
Claims exceeding the product's stated dispensing limit (quantity per specified days) may be denied during adjudication based on the product‑specific rules.
Cumulative limits across strengths can trigger denials
Requests that exceed cumulative quantity limits across strengths or formulations (for example, azithromycin 60 tablets per 180 days cumulative across strengths) may be denied.
Denial risk when NDC/label limits are exceeded
Claims exceeding specific NDC/label dispensing limits (for example, clozapine 25 mg ODT limits) are subject to denial if the listed per‑period quantity is exceeded.
Over‑period dispensing may require PA or be denied
Dispensing that exceeds stated per‑period quantity (for example, >30 tablets per 30 days for certain oncology agents) may trigger denial or require prior authorization/override.
Over‑limit requests for injectables risk denial
Examples indicate that dispensing requests above product limits (e.g., dulaglutide >4 pens per 28 days) may be denied unless appropriate authorization is obtained.
Denial risk for exceeding product‑specific quantities
Dispensing claims exceeding the listed product‑specific quantity per the specified days (many examples throughout the list) may be denied at adjudication.
Quantity‑limit enforcement may cause denials
Requests exceeding stated dispensing limits (for example, more than the specified tablets per 30 days for many oral agents) are subject to quantity‑limit enforcement and possible denial.
Cumulative triptan limits enforced (denial risk)
Quantity‑limit enforcement examples include cumulative triptan limits (maximum 18 oral triptan tablets per 30 days across agents); exceeding these limits may be denied.
Over‑limit opioid dispensing may be denied
Requests exceeding listed dispensing limits for certain ER opioids (e.g., >60 capsules per 30 days for some hydrocodone ER strengths) may be denied.
Insulin volume and pod limits enforced
Examples show per‑product limits such as >100 mLs per 30 days for many injectable insulins or >30 pods per 30 days for Omnipod reservoirs; exceeding these may be denied.
Limit on insulin syringes/needles (300 per 30 days)
Claims for more than 300 insulin syringes or pen needles per 30 days may be denied under the stated limits.
Biologic autoinjector per‑period limits carry denial risk
Requests that exceed stated per‑period quantity limits for biologic autoinjectors (for example, >1 syringe per 28 days for some products) may be denied.
Per-Product Quantity Limits (Selected Items)
Key Terms and Flags
Policy Background
Dispensing limits are administrative controls that define the maximum quantity of a medication covered per prescription or within a specified time window. They are intended to encourage medication use consistent with FDA guidance and to manage coverage access across drug classes and plan designs. Limits may vary by state and benefit plan and can apply cumulatively across strengths or formulations within a class.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.