BCBSNM dispensing limits policy update

Dispensing limit criteria

Dispensing limits apply as listed per product; where listed limit is lower than the prescribed quantity, coverage beyond the listed limit is not provided and the member is responsible for the excess.

Dispensing limits shown are the maximum covered quantity per specified period for the listed drug/product.

If a physician prescribes a greater quantity than the dispensing limit, the member may obtain the medication but is responsible for the full cost beyond coverage.

Some dispensing limits may not apply to all members and may vary by state regulation or specific benefit plan; certain categories may be limited to a 30‑day supply or excluded per plan materials.

Dispensing limits table (excerpt)

Product-specific dispensing limits and designation apply as listed; pharmacists should not dispense quantities exceeding the stated limit per time period.

Pharmacy must apply the product-specific dispensing limit (quantity and time window) as shown in the formulary list at point of sale.

Brand/generic designation flags (BG = Brand & Generic, B = Brand only, G = Generic only) apply per product entry.

Product-specific dispensing limits (excerpt)

Per-product dispensing limits and brand/generic flags as listed below (excerpt):

Mydayis (amphetamine-dextroamphetamine) ER 37.5 mg: 30 Capsules Per 30 DAYS (BG).

Adderall XR (amphetamine-dextroamphetamine ER) multiple strengths: 30 Capsules Per 30 DAYS (BG).

Adderall immediate-release tablets 20 mg: 90 Tablets Per 30 DAYS (BG).

Kineret (anakinra) 100 mg/0.67 ml prefilled syringe: 28 Syringes Per 28 DAYS (B).

Apixaban (Eliquis) 5 mg: 74 Tablets Per 30 DAYS (B).

Apremilast (Otezla) 30 mg: 60 Tablets Per 30 DAYS (B).

Per-drug dispensing limits (excerpt)

Per-drug dispensing limits and brand/generic status (examples from excerpt):

Azilsartan medoxomil 80 mg (Edarbi): 30 Tablets Per 30 DAYS (B).

Azithromycin 250 mg (Zithromax): 60 Tablets Per 180 DAYS; QL cumulative across strengths (BG).

Aztreonam lysine inhalation soln 75 mg (Cayston): 1 Kit Per 56 DAYS (B).

Baclofen oral solution 5 mg/5 ml: 2400 mLs Per 30 DAYS (BG).

Cabozantinib kit (Cometriq): 1 Kit Per 28 DAYS (B).

Calcipotriene foam 0.005%: 120 Grams Per 30 DAYS (B).

Example dispensing-limit criteria

Dispensing limits and formulary status for specific medications (examples extracted below).

Cabozantinib (Cabometyx) 20/40/60 mg tablets: 30 Tablets Per 30 DAYS (B).

Calcifediol 30 mcg (Rayaldee): 60 Capsules Per 30 DAYS (B).

Calcipotriene foam 0.005%: 120 Grams Per 30 DAYS (B).

Continuous glucose system receiver (Dexcom/Freestyle Libre): 1 Receiver Per 365 DAYS (B).

Continuous glucose system transmitter (Dexcom g6): 1 Transmitter Per 90 DAYS (B).

Crinecerfont oral solution 50 mg/ml: 120 mLs Per 30 DAYS (B).

Product dispensing limits

Product-specific dispensing limits (quantity and time window) and brand/generic availability:

Continuous glucose system receiver: 1 Receiver Per 365 DAYS (B).

Continuous glucose system transmitter (Dexcom g6): 1 Transmitter Per 90 DAYS (B).

Crizotinib (Xalkori) 200 mg: 120 Capsules Per 30 DAYS (B).

Cromolyn sodium nebu solution 20 mg/2 ml: 240 mLs Per 30 DAYS (G).

Cyclobenzaprine ER 15 mg (Amrix): 30 Capsules Per 30 DAYS (BG).

Cyclosporine ophthalmic emulsion (Restasis/Klarity-c): 60 Vials Per 30 DAYS or 1 Bottle Per 30 DAYS depending on formulation (BG/B).

Sample per-drug limits

Per-product dispensing limits (examples from this section):

Dexmethylphenidate (Focalin XR) ER 20–40 mg: 30 Capsules Per 30 DAYS (BG).

Dexmethylphenidate immediate‑release tablets (Focalin): 60 Tablets Per 30 DAYS (BG).

Dextroamphetamine ER (Dexedrine) 10–15 mg: up to 120 Capsules Per 30 DAYS (BG).

Injectable biologic/GLP-1 limits

Special agent limits and notes:

Dulaglutide (Trulicity) auto‑injector: 4 Pens Per 28 DAYS; fill limit of one injectable GLP‑1 agent and one strength per 28 days (refill window applies).

GLP‑1 injectable fill rule applies across agents.

Dupilumab (Dupixent) auto‑injector/syringe: typical limits 2 Pens Per 28 DAYS (200 mg) or 4 Pens Per 28 DAYS (300 mg); corresponding syringe limits shown per strength.

Cumulative class limits

Cumulative limits across drug classes:

Oral triptans and triptan combinations have a cumulative maximum of 18 tablets per 30 days across all agents.

Per-product dispensing limits (excerpt)

Per-product dispensing limits and brand/generic availability as listed below (examples from this excerpt):

Oriahnn (elagolix‑estradiol‑norethindrone pack): 56 Capsules Per 28 DAYS (B).

Relpax (eletriptan) 20 mg: 18 Tablets Per 30 DAYS (cumulative triptan limit applies) (BG).

Trikafta formulations: typically 56–84 units Per 28 DAYS depending on formulation (B).

Vowst (fecal microbiota spores) caps: 12 Capsules Per 12 MONTHS (B).

Sample dispensing limit criteria

Selected examples from the dispensing limit list with associated limits and availability flags.

Estradiol transdermal patch (Climara) weekly 0.1 mg/24 hr: 30 Patches Per 30 DAYS (BG).

Eszopiclone (Lunesta) 1–3 mg: 30 Tablets Per 30 DAYS (BG).

Enbrel (etanercept) prefilled syringe 25 mg/0.5 ml: 4 Syringes Per 28 DAYS (B).

Bydureon BCise (exenatide ER) auto‑injector: 4 Pens Per 28 DAYS; fill limit of one injectable GLP‑1 agent and one strength per 28 days (B).

Vowst: 12 Capsules Per 12 MONTHS (B).

Fluticasone furoate‑vilanterol (Breo Ellipta): 60 Blisters Per 30 DAYS (B).

Dispensing limit entries (excerpt)

Per-product dispensing limits and formulary designation entries shown below (partial list from the larger document).

Fluticasone‑salmeterol inhaler (Advair HFA): 1 Inhaler Per 30 DAYS (B).

Trelegy Ellipta (fluticasone‑umeclidinium‑vilanterol): 1 Inhaler Per 30 DAYS (B).

Follitropin alfa for injection (Gonal‑F) 1050 unit: 5 Vials Per 30 DAYS (B).

Follitropin beta injection 300 unit (Follistim Aq): 15 Cartridges Per 30 DAYS (B); each cartridge billed as 0.420 mL.

Fostamatinib (Tavalisse) 100 mg: 60 Tablets Per 30 DAYS (B).

Dispensing quantity and product designation criteria

Products listed include a per-period maximum quantity and a designation of whether brand, generic, or both are applicable.

Examples: idelalisib 150 mg: 60 Tablets Per 30 DAYS (B); iloperidone tablets: 60 Tablets Per 30 DAYS (B); imatinib 100 mg: 90 Tablets Per 30 DAYS (B).

Insulin formulations often have a 100 mLs Per 30 DAYS limit; limits are cumulative across injectable insulin formulations unless otherwise noted.

Device examples: Omnipod starter kit 1 Kit Per 720 DAYS; Omnipod reservoir pods: 30 Pods Per 30 DAYS.

Per-30-day dispensing quantity limits

Dispensing limits by product or device type (per 30 days):

Many insulin solutions and pen injectors (e.g., Humalog, Admelog, Lyumjev) are limited to 100 mLs Per 30 DAYS.

Afrezza inhalation cartridges: product‑specific per‑30‑day cartridge limits (examples: 2520, 1800, 1260, 1080, 900 cartridges per 30 days depending on presentation).

Insulin pen needles: 300 Insulin Pen Needles Per 30 DAYS; QL cumulative across all pen needles.

Insulin syringes: 300 Syringes Per 30 DAYS; QL cumulative across all insulin syringes.

Sample dispensing-limit criteria

Per-drug dispensing limits and brand/generic designation entries (examples shown):

Insulin syringes/needles (U‑100, various gauges): 300 Syringes Per 30 DAYS; cumulative across insulin syringes.

Interferon beta‑1a (Rebif Rebidose) auto‑inj 22 mcg/0.5 ml: 12 Syringes Per 28 DAYS; QL cumulative across strengths (B).

Ipratropium‑albuterol nebulizer solution 0.5–2.5 mg/3 ml: 540 mLs Per 30 DAYS (G).

Examples

Selected examples of dispensing limits and brand/generic designations from the Performance Select formulary.

Ebglyss (lebrikizumab) auto‑inject 250 mg/2 ml: 1 Pen Per 28 DAYS (B).

Harvoni (ledipasvir‑sofosbuvir) pellet packs/tabs: 28 Packs/Tablets Per 28 DAYS (B).

Lenacapavir (Yeztugo/Sunlenca) 300 mg: 4 Tablets Per 365 DAYS (B).

Lenalidomide (Revlimid) various strengths: typical limits 21–30 Capsules Per 28/30 DAYS depending on strength (BG).

Lidocaine topical formulations: 120 Each Per 30 DAYS; quantity limits may be cumulative across formulations (B/G/BG as listed).

Liraglutide (Victoza) pen injector: 3 Pens Per 30 DAYS; GLP‑1 fill limit applies (BG).

Per-drug dispensing limit entries (partial list)

Per-product dispensing limits and brand/generic designation (examples extracted from this portion of the document):

Lisdexamfetamine (Vyvanse) chewable tablets 20–60 mg: 30 Tablets Per 30 DAYS (BG).

Lisinopril oral solution (Qbrelis) 1 mg/ml: 2400 mLs Per 30 DAYS (B).

Lonafarnib (Zokinvy) 50–75 mg: 120 Capsules Per 30 DAYS (B).

Lorazepam tablets 0.5–2 mg (Ativan): 150 Tablets Per 30 DAYS (BG).

Lorlatinib (Lorbrena) 25–100 mg: examples include 120 or 30 Tablets Per 30 DAYS depending on strength (B).

Loteprednol etabonate ophthalmic suspension (Eysuvis): 16.6 mLs Per 90 DAYS (B).

Coding / NDC / Unit Limits

Example drug limitsmixed

Drug-specific dispensing limits (e.g., abacavir sulfate soln 20 mg/ml = 960 mLs Per 30 DAYS; abacavir sulfate tab 300 mg = 60 Tablets Per 30 DAYS)

Adalimumab productsmixedCovered

Adalimumab biosimilars and formulations listed with Dispensing Limit = 2 Syringes/Pens Per 28 DAYS (examples: Amjevita, Hadlima entries)

Albuterol productsmixedCovered

Albuterol sulfate nebulizer solutions and inhalers with specified dispensing limits (examples: 120 Vials Per 30 DAYS; 60 mLs Per 30 DAYS; 125 Vials Per 30 DAYS; 3 Inhalers Per 30 DAYS).

TriptansmixedCovered

Oral triptans (examples: almotriptan 6.25 mg and 12.5 mg) with Dispensing Limit = 18 Tablets Per 30 DAYS; note: quantity limit for oral triptans is cumulative (maximum 18 tablets per 30 days across all agents).

Drug dispensing limit entriesmixed

Examples of drug entries with dispensing limits and brand/generic flags (e.g., amphetamine-dextroamphetamine tab 20 mg (Adderall) = 90 Tablets Per 30 DAYS; anakinra 100 mg syringe = 28 Syringes Per 28 DAYS).

NDC/Drug-level (no codes listed)mixed

Medication names, strengths, dispensing limits, and brand/generic designation (e.g., azilsartan 80 mg = 30 Tablets Per 30 DAYS; c1 esterase inhibitor (Cinryze) 500 unit = 20 Vials Per 30 DAYS).

N/A - drug-level listingmixed

Cabozantinib (Cometriq) kits and Cabometyx tablets with Dispensing Limits (e.g., Cometriq kits = 1 Kit Per 28 DAYS; Cabometyx 20/40/60 mg = 30 Tablets Per 30 DAYS).

NDC/product-level (text)mixed

Continuous glucose system receivers/transmitters and oral/solution products listed with limits (e.g., 1 Receiver Per 365 DAYS; 1 Transmitter Per 90 DAYS; crinecerfont oral soln = 120 mLs Per 30 DAYS).

Stimulant agents (dexmethylphenidate)mixed

Dexmethylphenidate HCl (Focalin XR) extended-release capsule strengths listed with Dispensing Limit = 30 Capsules Per 30 DAYS (multiple strengths: 5, 20, 25, 30, 35, 40 mg).

GLP-1 agentsmixed

Dulaglutide (Trulicity) auto-injector strengths listed with Dispensing Limit = 4 Pens Per 28 DAYS; policy-level fill limit: one injectable GLP-1 agent and one strength per 28 days.

N/A - drug-level limitsmixed

Various drug names, strengths, and dispensing limits provided as product-level entries without CPT/HCPCS codes (examples include Trikafta, Relpax, Oriahnn entries).

Listed NDC/Codable products (text-only)mixed

Examples of product entries with dispensing limits and availability flags (e.g., Climara patch 0.1 mg/24hr = 30 Patches Per 30 DAYS; Enbrel prefilled syringe = 4 Syringes Per 28 DAYS).

Formulary designation codesmixed

BG|B|G

Brand/Generic designation used in list (BG = Generic and Brand; B = Brand Only; G = Generic only).

Medication dispensing examplesmixed

Per-product dispensing limits examples (e.g., iloperidone 8 mg = 60 Tablets Per 30 DAYS; imatinib 100 mg = 90 Tablets Per 30 DAYS; iloprost inhalation = 270 Ampules Per 30 DAYS).

Afrezza cartridge limitsmixedCovered

Afrezza inhalation powder cartridge presentations listed with per-30-day limits (example entries include Dispensing Limit = 1260 Cartridges Per 30 DAYS for certain presentations).

Insulin solution and pen productsmixedCovered

Multiple insulin pen and cartridge products (Humalog, Admelog, Lyumjev, Humulin R U-500, etc.) with Dispensing Limit = 100 mLs Per 30 DAYS (per listed product).

Delivery devices (pen needles / syringes)mixedCovered

Insulin pen needles and insulin syringes listed with Dispensing Limit = 300 Insulin Pen Needles Per 30 or 300 Syringes Per 30 DAYS; QL cumulative across all pen needles/insulin syringes.

Drug/formulation list (no procedure codes)mixed

Entries listing drug/formulation-level quantity limits without procedure codes (examples: various insulin syringes with 300 Syringes Per 30 DAYS limits).

Drug dispensing entriesmixed

Selected drug entries with dispensing limits and BG/B/G flags (examples: Ebglyss auto-inject = 1 Pen Per 28 DAYS; Harvoni packs = 28 Packs Per 28 DAYS; lenacapavir = 4 Tablets Per 365 DAYS).

N/A - drug listmixed

Per-product dispensing limit entries (examples: Vyvanse strengths = 30 Tablets Per 30 DAYS; lisinopril oral soln = 2400 mLs Per 30 DAYS; lonafarnib 50 mg = 120 Capsules Per 30 DAYS).

Example unit-per-period thresholds

Example mL limit1.56 mLs Per 30 DAYS (abaloparatide pen = 1 injection)

Example syringe limit4 Syringes Per 28 DAYS (abatacept prefilled syringe)

Example tablet limit60 Tablets Per 30 DAYS (abemaciclib example)

Adalimumab pens/syringes per 28 days

Adalimumab pens/syringes2 Pens or 2 Syringes Per 28 DAYS

Product examplesAmjevita, Hadlima entries show 2 per 28 days

Formulary flagMany adalimumab entries designated Brand (B)

Albuterol inhalers per 30 days

Albuterol inhalers2 Inhalers Per 30 DAYS

Product examplesProair Respiclick, Proair Digihaler, Ventolin HFA — 2 per 30 days

Formulary flagSome inhaler entries designated Brand (B) or BG

Oral triptans cumulative per 30 days

Oral triptan cumulative limit18 Tablets Per 30 DAYS (cumulative across all oral triptans and combinations)

Product examplesAlmotriptan and eletriptan entries list 18 tablets per 30 days

Applies across agentsLimit is cumulative across different oral triptans and triptan combinations

Albuterol nebule vials per 30 days

Albuterol nebule vials (common)120 Vials Per 30 DAYS

Alternate vial counts125 Vials Per 30 DAYS for some 2.5 mg/3 mL formulations

mL volume option60 mLs Per 30 DAYS listed for some nebulizer solution formulations

Common quantity limit windows

Common windowsPer 28 / Per 30 / Per 56 / Per 90 / Per 180 DAYS (product-specific)

Kit examples1 Kit Per 28 DAYS or 1 Kit Per 180 DAYS for selected products

Long-window examples1 Receiver Per 365 DAYS; 1 Transmitter Per 90 DAYS for CGM devices

Example dispensing limit format

Dispensing limit format example30 Tablets Per 30 DAYS (example formatting used throughout list)

Cumulative note exampleSome entries include 'QL cumulative across strengths' (e.g., azithromycin)

Unit examplesFormats include '1 Kit Per 28 DAYS', '120 Grams Per 30 DAYS'

Maximum quantity per period (examples)

30 tablets / 30 days30 Tablets Per 30 DAYS (common oral solid example)

Kit per period1 Kit Per 28 DAYS (e.g., Cometriq kits)

Annual kit example58 Kits Per 365 DAYS (caplacizumab example)

Common dispensing thresholds

Device thresholds1 Receiver Per 365 DAYS; 1 Transmitter Per 90 DAYS (CGM devices)

Starter kit frequency1 Kit Per 720 DAYS (insulin pump starter kits)

Oral product common limitMany oral products limited to 30 Tablets Per 30 DAYS

Oral triptan monthly cumulative limit

Monthly cumulative triptan limit18 Tablets Per 30 DAYS across all oral triptans (cumulative)

Specific products notedAlmotriptan entries list 18 per 30 days; eletriptan similarly constrained

Policy applicationCumulative limit applies across agents and combinations

Cumulative triptan limit (policy)

Cumulative ruleMaximum of 18 Tablets Per 30 DAYS across all oral triptans and triptan combinations (cumulative QL)

ExamplesAlmotriptan 6.25 mg and 12.5 mg both list 18 Tablets Per 30 DAYS

Billing implicationPharmacy must apply cumulative count across different triptan SKUs

Vowst annual limit

Vowst annual limit12 Capsules Per 12 MONTHS

Productfecal microbiota spores, live-brpk caps (Vowst)

Formulary flagDesignated Brand (B)

Quantity limits (per-product examples)

Inhaler example1 Inhaler Per 30 DAYS (e.g., Trelegy Ellipta)

Tablet example60 Tablets Per 30 DAYS (common for many agents)

Pen example3 Pens Per 84 DAYS or 4 Pens Per 28 DAYS depending on product

Pods per 30 days

Pods per 30 days30 Pods Per 30 DAYS (insulin infusion disposable pump reservoirs)

Applicable devicesOmnipod Gen 3/4/5 and compatible pods listed with 30 per 30 days

Formulary flagDesignated Brand (B) for many pod entries

Starter kit frequency

Starter kit frequency1 Kit Per 720 DAYS (insulin pump starter kits)

ExamplesOmnipod starter kits and insulin pump device limits use 720-day starter frequency

Plan noteStarter kit limits are product-specific and listed in the table

Insulin solution/pen limit

Insulin solution/pen limit100 mLs Per 30 DAYS (common limit for many insulin pens and solutions)

Cumulative noteApplies to many insulin solutions/pen-injectors listed (Humalog, Lyumjev, Admelog, etc.)

Formulary flagTypically Brand (B) or BG depending on product

Pen needle threshold

Pen needle threshold300 Insulin Pen Needles Per 30 DAYS; QL cumulative across all pen needles

Device examplesMultiple gauge/length pen needles listed with 300 per 30 days

Applies to all SKUsQL cumulative means limit totals across different pen needle SKUs

Syringe threshold

Syringe threshold300 Syringes Per 30 DAYS; QL cumulative for all insulin syringes

ExamplesVarious U-100 0.3 mL and 0.5 mL syringes listed with 300 per 30 days

Cumulative applicationLimit applies across all syringe SKUs (cumulative) at POS

Example per-period limits (selected)

Rebif syringe example12 Syringes Per 28 DAYS for interferon beta-1a (Rebif Rebidose)

Atrovent HFA / similar inhaler example2 Inhalers Per 30 DAYS (Atrovent HFA or similar inhalers)

General per-period exampleVarious entries show product-specific per-period limits (e.g., 12 syringes/28 days; 2 inhalers/30 days)

Annual tablet limit example

Annual tablet limit4 Tablets Per 365 DAYS (lenacapavir sodium 300 mg examples)

Productlenacapavir sodium tab 300 mg (Yeztugo / Sunlenca therapy packs)

ApplicationAnnual limits applied where clinically appropriate and listed per product

Dispensing limit examples (formats & units)

Tablet/capsule/patch/mL examplesExamples include '30 Tablets Per 30 DAYS', '120 Grams Per 30 DAYS', '12 Capsules Per 12 MONTHS', '100 mLs Per 30 DAYS'

Format consistencyDispensing limits consistently presented as '[quantity] [unit] Per [time period]'

Cumulative notesSome items note 'QL cumulative across strengths' where relevant

Provider / Pharmacist Actions & Warnings

Denial Risk

Member financial responsibility when exceeding limit

If a prescribed quantity exceeds a dispensing limit, the member may still obtain the medication but is responsible for the full cost beyond coverage.

Dispensing limits restrict the quantity of covered medication per prescription or within a time period (e.g., per 28 or 30 days).
Some limits are cumulative across strengths or agents within a class (see triptan and insulin rules).
Verify member-specific plan materials or call the number on the member ID card for plan-specific exceptions or state-regulated variations.

Billing Rule

Dispensing limits for adalimumab products

Adalimumab products have per‑28‑day dispensing limits by presentation (syringes, pens) and are identified with brand/designation flags. Prescribers and pharmacists should ensure quantity dispensed does not exceed the stated limit or the member will incur full cost for amounts beyond coverage.

Examples: Amjevita (adalimumab-atto) prefilled syringes — Dispensing Limit = 2 Syringes Per 28 DAYS (20 mg/0.4 mL, 40 mg/0.4 mL, 40 mg/0.8 mL).
Hadlima/Hadlima Pushtouch (adalimumab-bwwd) auto‑injectors — Dispensing Limit = 2 Pens Per 28 DAYS (40 mg/0.4 mL, 40 mg/0.8 mL); Hadlima prefilled syringe — Dispensing Limit = 2 Syringes Per 28 DAYS.
Each listed adalimumab entry includes a Brand/Generic designation (e.g., B for Brand Only in the examples above).

Denial Risk

Triptan cumulative limit

Oral triptans (and triptan combinations) are subject to a cumulative quantity limit across all agents. When adjudicating or counseling patients, apply the cumulative cap to the member's fills across different triptan products.

Cumulative limit: maximum of 18 tablets per 30 days across all oral triptans and triptan combinations.
Examples in list: almotriptan (6.25 mg and 12.5 mg) — Dispensing Limit = 18 Tablets Per 30 DAYS; eletriptan (20 mg and 40 mg) — Dispensing Limit = 18 Tablets Per 30 DAYS.

Note

Dispensing limits examples

Representative dispensing-limit examples (common formulations) are provided to illustrate how limits are applied by product, strength, and packaging. Use these examples to guide dispensing and member counseling.

Stimulant examples: Mydayis (amphetamine‑dextroamphetamine) 37.5 mg or 50 mg — Dispensing Limit = 30 Capsules Per 30 DAYS; Adderall XR strengths — Dispensing Limit = 30 Capsules Per 30 DAYS.
Albuterol examples: inhalers — Dispensing Limit = 2 Inhalers Per 30 DAYS (see albuterol entries for specifics); nebule vials or solution volumes list vial or mL limits per 30 days.
Kits and specialty products: Cometriq kits — Dispensing Limit = 1 Kit Per 28 DAYS.

Documentation Required

Dispensing limits and brand/generic designation

Many entries include a dispensing limit plus a Brand/Generic designation flag. Pharmacists should use both the numeric limit and the B/BG/G flag when determining coverage adjudication and substitution rules.

The BG/B/G flags indicate how the product is listed for Performance Select (BG = Brand and Generic, B = Brand Only, G = Generic Only).
Examples: albuterol nebule solutions often listed as BG (both brand and generic allowed); certain specialty brands (e.g., Trulicity, Repatha) are flagged B (Brand Only).
When multiple formulations of the same active drug are listed, confirm whether limits are cumulative across formulations as noted (e.g., insulin and triptans).

Note

Dispensing limits listing (no auth rules shown)

The dispensing limits listing provides per-product limits (e.g., units per 28/30/90/365 days) without showing prior authorization or step‑therapy rules in the excerpt. For operational use, apply the listed numeric limits and consult plan materials for any additional coverage controls.

Limits are expressed as units per time period (e.g., 2 Pens Per 28 DAYS, 120 Vials Per 30 DAYS, 1 Receiver Per 365 DAYS).
Some limits are package‑based (e.g., 1 package = 2 mLs = 2 pens for certain PCSK9 agents) — use package definitions when adjudicating quantity.
This excerpt does not show prior authorization or step‑therapy rules; check the full policy or PBM system for those controls.

Billing Rule

Insulin cumulative quantity rule and dispensing limits

Insulin products and related supplies generally have per‑30‑day volume or count limits; many insulin solution and pen formulations use a 100 mL per 30 days cap, and syringes/pen needles use cumulative quantity limits across all brands.

General insulin cumulative rule: many insulin products have a Dispensing Limit = 100 mLs Per 30 DAYS; limits are cumulative across formulations unless otherwise specified.
Examples of insulin with 100 mL/30 days limits: insulin aspart (Novolog/Relion), insulin lispro (Humalog), insulin lispro-aabc (Lyumjev), insulin aspart protamine/aspart mixes (Novolog Mix 70/30), Humalog Mix formulations.
Inhaled and concentrated insulins: Afrezza and U-500 formulations have specific cartridge or 100 mL limits respectively (Afrezza entries list cartridges per 30 days).
Supplies: Insulin pen needles — Dispensing Limit = 300 Insulin Pen Needles Per 30 DAYS (QL cumulative across all pen needles). Insulin syringes — Dispensing Limit = 300 Syringes Per 30 DAYS (QL cumulative across all insulin syringes).

Definitions and Flags

Dispensing limit definition

Dispensing Limit (definition)Quantity of covered medication per prescription or in a given time period; may be applied per drug or across a drug class.

Member financial responsibilityIf prescribed quantity exceeds dispensing limit, member may obtain medication but is responsible for full cost beyond coverage.

ApplicationLimits apply per product as listed; some limits may vary by plan or state and may be cumulative across related agents.

Member pays full cost beyond coverage

Member pays beyond coverageMember is responsible for the full cost of prescription amounts exceeding the dispensing limit.

Coverage noteCoverage beyond the limit is not provided; members can still obtain medication but at their expense.

Where to verifyMembers should check plan materials or call the number on the back of their ID card for plan-specific limitations.

Dispensing Limit (definition & examples)

Dispensing Limit (concise)Maximum quantity of a drug allowed to be dispensed within the specified period (e.g., syringes, pens, inhalers, tablets, mLs, vials).

Example'4 Syringes Per 28 DAYS' or '2 Pens Per 28 DAYS' are dispensing limits listed for biologics.

ApplicationApplied per drug or across a drug class where noted (cumulative QL).

Brand/generic designation codes (BG/B/G)

BG = Generic and BrandIndicates both generic and brand formulations are referenced (BG)

B = Brand OnlyIndicates brand-only availability (B)

G = Generic OnlyIndicates generic-only availability (G)

Dispensing limit example

Dispensing limit example format30 Capsules Per 30 DAYS (example used in the document)

Cumulative QL noteSome entries include cumulative QL across strengths (e.g., azithromycin entries)

UnitsFormats use units such as Tablets, Capsules, Patches, mLs, Vials, Pens, Kits

BG/B/G flag explanation

BG/B/G flags explainedBG = Generic and Brand; B = Brand Only; G = Generic Only

UsageFlags appear alongside dispensing-limit entries to indicate formulary availability

Multiple occurrencesFlag definitions are repeated throughout the document for clarity

Dispensing Limit (format)

DL format[quantity] [unit] Per [time period] (e.g., '28 Tablets Per 28 DAYS')

Examples'120 Grams Per 30 DAYS', '1 Kit Per 56 DAYS'

Cumulative notes'QL cumulative across strengths' used where applicable

Brand/Generic designation (BG/B/G)

BG/B/G designationBG = Generic and Brand; B = Brand Only; G = Generic Only

PurposeIndicates whether listed product entries include brand, generic, or both formulations

Applied per line-itemFlags accompany each dispensing-limit line for clarity at POS

QL cumulative (quantity limits across SKUs)

QL cumulative (definition)Quantity limits noted as 'QL cumulative' apply in total across different SKUs of the same device type (e.g., pen needles, syringes)

ExamplesInsulin pen needles and insulin syringes noted as QL cumulative at 300 per 30 days

ImplicationPharmacy must total quantities across SKUs when enforcing the limit

Dispensing Limit / QL notation

DL / QL notationDL (Dispensing Limit) / QL (Quantity Limit) denote maximum quantity permitted per listed interval

Common periodsPeriods commonly used: Per 28 DAYS, Per 30 DAYS, Per 90 DAYS, Per 365 DAYS

ApplicationUsed at pharmacy POS to determine covered quantity; amounts beyond DL/QL are member financial responsibility

BG/B/G coding definitions

BG/B/G coding definitionsBG = Generic and Brand; B = Brand Only; G = Generic only

Repeated usageDefinitions are reiterated throughout the list for clarity

Applies to each listed productFlag indicates availability/applicability per line item

OpenPayer

Performance Select Dispensing Limits (DL)

Dispensing Limit Coverage Criteria

Coding / NDC / Unit Limits

Provider / Pharmacist Actions & Warnings

Definitions and Flags