Blue Cross Blue Shield NM dispensing limits Coverage

inv-01: Dispensing limit criteria and examples

Covered with dispensing limits; member financial responsibility and plan variability:

Dispensing limits are applied to specific medications and specify maximum quantity per prescription or within a stated time period (e.g., Per 28 DAYS, Per 30 DAYS).

If a prescriber orders a greater quantity than the dispensing limit, the member may still obtain the medication but is responsible for the full cost of the quantity in excess of the coverage limit.

Dispensing limits may vary by plan or state; some drugs or categories may be excluded from mail service or limited to 30-day supplies depending on the member’s benefit plan. Members should consult plan materials or contact member services to verify applicability.

inv-02: Dispensing limits (examples)

Selected examples illustrating common dispensing limits and formulary flags:

Adalimumab formulations (multiple branded and biosimilar products): commonly limited to 2 Pens or 2 Syringes Per 28 DAYS or Kit Per 28 DAYS; form-specific BG/B flags shown.

Albuterol sulfate inhaler (Albuterol Sulfate Hfa): Dispensing Limit = 2 Inhalers Per 30 DAYS (6 packages per 90 days noted elsewhere).

Almotriptan and other oral triptans: cumulative limit of 18 Tablets Per 30 DAYS across oral triptans (cumulative QL applies across agents).

Azithromycin formulations (Z-Pak/Tri-Pak): Dispensing Limit = 60 Tablets Per 180 DAYS, QL cumulative across strengths.

inv-03: listed_products_dispensing_limits_and_status

Per-product dispensing limits and formulary availability (no clinical prior authorization or medical necessity criteria provided here):

Some hemophilia factor products: dispensing limits expressed as mL Per 30 DAYS and are dependent on patient weight and number of doses; form shows BG/B flags.

Belimumab (Benlysta) subcutaneous solution prefilled syringe 200 mg/mL: Dispensing Limit = 4 Syringes Per 28 DAYS; designated Brand (B).

Aztreonam lysine for inhalation (Cayston) 75 mg: Dispensing Limit = 84 mLs Per 56 DAYS (1 kit = 84 vials = 84 mL); designated Brand (B).

Apixaban starter pack and tablet entries show pack- or tablet-based dispensing limits (e.g., Pack Per 180 DAYS for starter packs; tablet limits per 30 DAYS as specified).

inv-04: Specified quantity limits

Specified product quantity limits and brand/generic status (coverage subject to these limits):

Azithromycin 250 mg tablets (Zithromax Z‑Pak / Tri‑Pak): Dispensing Limit = 60 Tablets Per 180 DAYS; QL cumulative across strengths; Formulary = BG.

Belimumab subcutaneous solution prefilled syringe 200 mg/mL (Benlysta): Dispensing Limit = 4 Syringes Per 28 DAYS; Formulary = B.

Budesonide inhalation suspension (Pulmicort) examples: Dispensing Limit = 120 mLs Per 30 DAYS; Formulary indicated as BG in entries.

Clobetasol propionate cream 0.025%: Dispensing Limit = 100 Grams Per 30 DAYS; 100/30 cumulative across agents; Formulary = B.

inv-05: Dispensing limits and access rules (excerpt)

Examples of per-product dispensing limits and access rules:

Mavenclad (cladribine) 10 mg pack (9 tablets): Dispensing Limit = 9 Tablets Per 301 DAYS.

Clarithromycin ER 500 mg: Dispensing Limit = 28 Tablets Per 180 DAYS.

Clobetasol propionate cream 0.025%: Dispensing Limit = 100 Grams Per 30 DAYS with cumulative 100/30 across agents noted.

Continuous glucose monitoring receivers: Dispensing Limit = 1 Receiver Per 365 DAYS; transmitters limited per 90 DAYS (product-specific limits).

Coagulation factor products: dispensing limits specified in mL Per 30 DAYS and depend on patient weight and number of doses.

inv-06: sample coverage limits

Selected coverage examples with formulary status and cumulative-limit notes:

Desogestrel & ethinyl estradiol combination tablets: Dispensing Limit = 28 Tablets Per 21 DAYS; Formulary flags shown.

Desoximetasone topical formulations (cream/gel/ointment/spray): typical limits 90–100 Grams or mLs Per 30 DAYS with 100/30 cumulative across agents.

Dupilumab auto-injector 200 mg/1.14 mL: Dispensing Limit = 2 Pens Per 28 DAYS; Formulary = B.

Dolutegravir (Tivicay) 10 mg: Dispensing Limit = 240 Tablets Per 30 DAYS; Formulary = B.

Oral triptans (e.g., almotriptan, eletriptan, rizatriptan): cumulative maximum of 18 Tablets Per 30 DAYS across oral triptans and triptan combinations.

inv-07: Dispensing quantity limits (excerpted)

Dispensing quantity limits (excerpt) with product designation where shown:

Emtricitabine (Emtriva) capsules 200 mg: Dispensing Limit = 30 Capsules Per 30 DAYS; designation BG noted for tablets and B for solutions.

Fixed‑dose combination antiretrovirals (e.g., Complera, Descovy, Truvada): typically 30 Tablets Per 30 DAYS (formulary flags BG or B as listed).

Enfuvirtide (Fuzeon): Dispensing Limit = 60 Vials Per 30 DAYS; Formulary = B.

Erenumab (Aimovig): Dispensing Limit = 1 Injection Device Per 28 DAYS; Formulary = B.

inv-08: Sample product-specific limits

Sample product-specific dispensing limits with formulary indicators:

Fluticasone furoate‑vilanterol (Breo Ellipta): Dispensing Limit = 1 Inhaler Per 30 DAYS; Formulary = B.

Flovent Diskus variants (fluticasone propionate): dispensing limits expressed as Blisters Per 30 DAYS (examples: 60 or 240 Blisters Per 30 DAYS); Formulary = B.

Fremanezumab (Ajovy) 225 mg: Dispensing Limit = 3 Injection Devices Per 84 DAYS; Formulary = B.

Glucose test strips example (D‑Care): Dispensing Limit = 204 Strips Per 30 DAYS; Formulary = B.

Insulin degludec and many insulin products: Dispensing Limit = 100 mLs Per 30 DAYS (quantity limits cumulative across injectable formulations); Formulary entries indicate B in many lines.

inv-09: Dispensing limits and formulary indicators

Product-level dispensing limits and formulary status (examples):

Imiquimod cream 2.5% (Zyclara Pump): Dispensing Limit = 2 Bottles Per 180 DAYS; Formulary = B.

Imiquimod cream 5%: Dispensing Limit = 48 Packets Per 180 DAYS; Formulary = G.

Infliximab‑dyyb (Zymfentra) prefilled syringe/kit presentations: Dispensing Limit = kit/pen/syringe per 28 DAYS as specified; Formulary flags vary by presentation.

Insulin pen needles and insulin syringes (multiple SKUs): Dispensing Limit = 300 Units Per 30 DAYS, with QL cumulative across all pen needles/syringes; Formulary = B in entries.

Multiple insulin products (Lantus, Basaglar, Toujeo, Semglee, etc.): Dispensing Limit = 100 mLs Per 30 DAYS (cumulative across injectable formulations).

inv-10: Examples of dispensing limit criteria

Additional product examples and limits (illustrative):

Insulin syringes (various sizes): Dispensing Limit = 300 Units Per 30 DAYS; QL cumulative across insulin syringes.

Ixekizumab (Taltz): Dispensing Limit = 1 Syringe Per 28 DAYS; Formulary = B.

Ledipasvir‑sofosbuvir (Harvoni) formulations: Dispensing Limit = 28 Packets or Tablets Per 28 DAYS; Formulary = B.

Isotretinoin (Absorica) examples: Dispensing Limit = 60 Capsules Per 30 DAYS; Formulary = BG.

inv-11: Dispensing limits (selected)

Selected excerpt noting dispensing limits and brand/generic status for listed products (no medical necessity criteria included):

Entries in this segment specify product name, strength/form, dispensing limit expressed per stated period (commonly Per 30 DAYS or Per 28 DAYS), and BG/B/G formulary designation where available.

inv-12: Selected dispensing rules

Selected dispensing rules and product status examples from this segment:

Metformin HCl ER 1000 mg: Dispensing Limit = 60 Tablets Per 30 DAYS; Formulary designation = G.

Methylnaltrexone bromide injections (Relistor): Dispensing Limits include 30 Syringes Per 30 DAYS (18 mL) and 60 Vials Per 30 DAYS; Formulary = B; the 60‑vial QL may accommodate dosing for very high weight individuals.

Mirikizumab (Omvoh): Dispensing Limit = 2 Pens Per 28 DAYS; Formulary = B.

Nirmatrelvir + ritonavir (Paxlovid) pack formulations: multiple pack-based dispensing limits shown (e.g., 20–30 Tablets Per 90 DAYS depending on pack); Formulary = B in entries.

inv-13: Sample dispensing limit entries from partial list

Representative limit entries from the partial list with formulary designation:

Olanzapine 7.5 mg (Zyprexa): Dispensing Limit = 60 Tablets Per 30 DAYS; Formulary = BG.

Omeprazole magnesium suspension packets (Prilosec): Dispensing Limit = 30 Packets Per 30 DAYS; Formulary = B.

Oseltamivir (Tamiflu) entries: Dispensing Limits vary by strength with cumulative QL across strengths (e.g., 40 Capsules Per 120 DAYS for 30 mg; 20 Capsules Per 120 DAYS for other strengths); Formulary = BG.

Rimegepant (Nurtec) disintegrating tablets 75 mg: Dispensing Limit = 54 Tablets Per 90 DAYS; Formulary = B.

inv-14: Drug dispensing limits (excerpt)

Selected drug-specific dispensing limits and product designation examples:

Resmetirom (Rezdiffra) 100/60/80 mg tablets: Dispensing Limit = 30 Tablets Per 30 DAYS; Formulary = B where noted.

Rifaximin 200 mg: Dispensing Limit = 9 Tablets Per 30 DAYS; Rifaximin 550 mg: Dispensing Limit = 60 Tablets Per 30 DAYS (Formulary = B for 550 mg).

Risankizumab (Skyrizi) cartridge and pen presentations: Dispensing limits shown per 56–84 day intervals depending on presentation; Formulary = B.

inv-15: Dispensing quantity limits

Additional per-product dispensing limits and notes on cumulative limits:

Sitagliptin (and combination Janumet XR) entries: common Dispensing Limits = 30–60 Tablets Per 30 DAYS depending on product/strength; Formulary = B in many entries.

Sodium oxybate oral solution: Dispensing Limit = 540 mLs Per 30 DAYS; Formulary = B.

Tafamidis (Vyndamax/Vyndaqel) examples: Dispensing Limits = 30 Capsules Per 30 DAYS (Vyndamax) and 120 Capsules Per 30 DAYS (Vyndaqel cardiac); Formulary = B.

Some products have cumulative quantity limits across agents or strengths (e.g., oral triptans, certain topical corticosteroids); these cumulative rules are noted where applicable.

Provider Impact and Actionable Notes

Note

Member cost responsibility and variability of dispensing limits

If a prescriber writes a quantity that exceeds the plan's dispensing limit, the member may still fill the prescription but will be responsible for the cost of the quantity beyond coverage. Dispensing limits may vary by state, by member benefit, and by drug class; some limits are cumulative across strengths or across agents within a class. Verify member-specific coverage and limits via plan materials or the phone number on the back of the member ID card.

Member cost responsibility when limits exceeded: member pays full cost for quantity beyond the dispensing limit.
Limits may differ by state or benefit design and some drugs/categories may be excluded from certain channels (e.g., mail).
Some dispensing limits apply cumulatively across strengths or agents within a drug class.

Prior Authorization

Adalimumab and biosimilar dispensing limits

Multiple adalimumab products (brands and biosimilars) have dispensing limits commonly set to 2 pens or 2 syringes per 28 days, or kit per 28 days depending on the presentation. Examples include branded and biosimilar presentations such as Cyltezo, Abrilada, Yusimry, Amjevita, Adalimumab-Ryvk, Simlandi and others — each entry may specify Pens, Syringes, or Kit per 28 DAYS.

Adalimumab-adbm (Cyltezo) prefilled syringe kit 40 mg/0.8 mL: Kit per 28 days or 2 Syringes or 2 Pens per 28 days depending on listing.
Adalimumab-afzb (Abrilada) auto-injector kits and prefilled syringes: typically 2 Pens or 2 Syringes per 28 days.
Adalimumab-aqvh (Yusimry), adalimumab-atto (Amjevita), adalimumab-ryvk (Simlandi/Adalimumab-Ryvk) and other biosimilars: typically 2 Pens or 2 Syringes per 28 days; some listings show Kit per 28 days.

Billing Rule

Dispensing limits and conditions (strength/formulation/weight dependent)

Dispensing limits are specified per product and may be expressed as mL per X days, packs per X days, tablets per X days, pens/kits per X days, or inhalers/cartridges per X days. Some limits depend on strength or formulation, and some are weight- or dose-dependent (particularly for certain injectables).

Examples of formats: 'mL Per 30 DAYS', 'Tablets Per 30 DAYS', 'Inhalers Per 30 DAYS', 'Kit Per 28 DAYS', 'Pens Per 180 DAYS'.
Some biologic or specialty injectables list limits as mL per 30 days and note dependence on patient weight and number of doses.
Combination products often translate pen limits to mL (e.g., 6 pens = 18 mL).

Note

Cumulative quantity limits across strengths/agents

Certain entries indicate quantity limits that are cumulative across strengths or across agents in a class. Where noted, the cumulative limit applies across all appropriate formulations or agents.

Azithromycin: quantity limits are cumulative across strengths (e.g., 60 tablets per 180 days cumulative across strengths).
Oral triptans and triptan combinations: cumulative maximum of 18 tablets per 30 days across all agents.
Some insulin syringe and injectable formulations: quantity limits noted as cumulative across injectable formulations.

Documentation Required

Dispensing limits and brand/generic indicators

Dispensing limits lists include an indicator of Brand/Generic access: BG = Generic and Brand, B = Brand only, G = Generic only. This designation is used for pharmacy claims adjudication and affects which NDCs or products are payable under the limit.

BG = both Generic and Brand products are included under the listing.
B = Brand-only coverage or designation for that product line.
G = Generic-only designation where applicable.

Billing Rule

Product dispensing limits and access flags

Product-level access flags and dispensing limits are listed for many products and should be used during claims adjudication to determine allowed quantities and whether a specific brand or generic is permitted.

Examples: Proair Respiclick (albuterol inhaler) — 2 inhalers per 30 days (B).
Apixaban (Eliquis) 2.5 mg — 60 tablets per 30 days (B).
Azithromycin Z-Pak formulations — 60 tablets per 180 days, QL cumulative across strengths (BG).

Denial Risk

Cumulative desoximetasone dispensing limit

Desoximetasone topical formulations have cumulative limits across agents — total topical/desoximetasone products are limited to specified gram/mL amounts per 30 days across formulations.

Desoximetasone cream 0.25% (Topicort): 100 grams per 30 days, cumulative across agents (100/30).
Desoximetasone gel 0.05%: 90 grams per 30 days, cumulative to a 100 grams per 30 days cap across agents.
Desoximetasone ointment 0.25% and spray formulations: included in the 100/30 grams or mLs cumulative limit across agents.

Note

Product dispensing limits (sample conversions and examples)

Sample product dispensing examples illustrate common limit formats and conversions (pens to mL, kits, bottles), which help interpret plan rules.

Soliqua 100/33 (insulin glargine-lixisenatide): 6 pens per 30 days = 18 mL.
Mavenclad (cladribine) 9-tablet pack: 9 tablets per 301 days (pack-based limit).
Annovera (segesterone acetate-ethinyl estradiol ring): Ring per 365 days, max 365 days per prescription.

Note

Dispensing limits listing (no prior authorization specified in excerpt)

The dispensing limits listing includes many product-specific entries used for pharmacy claims adjudication. The excerpted list does not include prior authorization instructions for most products — limits alone determine quantity allowable at point of sale unless a separate PA rule applies elsewhere.

Many entries are purely dispensing limits with BG/B/G flags and no prior authorization steps shown in the excerpt.
Examples in the excerpt: numerous inhalers, tablets, injectables and biologics with per-day or per-period limits but no PA instruction included in the same line.

Note

Dispensing limits listing (no PA instructions in excerpt)

Some segments list dispensing limits and brand/generic designation without accompanying prior authorization instructions in the excerpt. Clinicians should check the full policy or PA rules for any additional requirements.

Infliximab and related biologics: limits shown (pens, kits, syringes per 28 days) but PA steps, if required, are not present in the excerpt.
Specialty injectables often show mL-per-period limits dependent on weight/dosing but PA instructions may be located elsewhere in policy documents.

Billing Rule

Dispensing limits and brand/generic designation (partial examples)

Be aware of specific product-level dispensing limits and brand/generic designation that influence dispensing at pharmacy claim adjudication — these partial listings are actionable for prescribing and dispensing decisions.

Olanzapine (Zyprexa) 7.5 mg — 60 tablets per 30 days (BG).
Secukinumab (Cosentyx) 75 mg/0.5 mL — 1 syringe per 28 days (B).
Apixaban (Eliquis) and other commonly prescribed agents include clear tablet-per-period limits to guide refills.

Note

Extended-duration dispensing — Annovera

Extended-duration contraceptive products have clear per-prescription limits reflecting their multi-month duration.

Annovera contraceptive ring: Dispensing Limit = Ring per 365 days; maximum 365 days supplied per prescription.

Documentation Required

Cumulative quantity limit notes (operational reminder)

Quantity-limit notes reiterate that some limits are cumulative across agents or formulations and that prescribers and pharmacies must consider cumulative totals when evaluating refill eligibility.

Oral triptans cumulative limit: maximum 18 tablets per 30 days across all triptan agents.
Some sleep agents and other classes (e.g., suvorexant) have cumulative QLs across agents; check product listings for 'QL cumulative across agents' language.
Insulin syringes and injectable formulations may have cumulative quantity limits across formulations and package types.

Definitions and Legend

inv-76: limits — drug dispensing limits (definition)

DefinitionDrug dispensing limits — coverage constraints that limit the quantity of a medication that may be dispensed per prescription or within a specified time period to encourage appropriate use and align with benefit design.

ScopeMay apply to specific products, formulations, or classes and can vary by plan or state; some drugs may be limited to 30-day supplies or excluded from mail service.

EnforcementLimits are used during pharmacy claims adjudication to cap covered quantity; members may still obtain excess supply but are responsible for costs beyond coverage.

inv-77: dispensing limit details — dispensing limits may refer to quantity per prescription or quantity over a time period; limits may vary by state or plan.

What limits refer toQuantity per prescription or total quantity over a time period (e.g., per 28 days, per 30 days, per 180 days).

VariabilityLimits may vary by state or plan; some medications or categories may be excluded or limited to certain channels (e.g., not available by mail).

Cumulative rulesSome limits apply cumulatively across strengths or therapeutically related agents within a class.

inv-78: Dispensing Limit — maximum quantity of a product that may be dispensed in the stated time period (e.g., Per 28 DAYS, Per 30 DAYS).

Dispensing Limit (definition)Maximum quantity of a product that may be dispensed within the stated time period (examples shown: Per 28 DAYS, Per 30 DAYS).

Example unitKit Per 28 DAYS (adalimumab-adbm Cyltezo examples).

Typical cadenceMany biologic pen/syringe products use a Per 28 DAYS window for limits.

inv-79: Generic and Brand (BG) / Brand Only (B) / Generic only (G) — designation indicating whether the product is covered as generic and brand, brand only, or generic only.

Coverage designationBG/B/G flags indicate whether both generic and brand, brand only, or generic only versions are allowed for the product listing.

Example in listAdalimumab entries show B (Brand) designation for many prefilled syringe/pen kits.

Use in adjudicationFormulary designation guides which product versions are covered when applying dispensing limits at claim time.

inv-80: quantity allowed to be dispensed in the specified time period — Dispensing Limit.

Quantity allowed (example)Azithromycin 250 mg — Dispensing Limit = 60 Tablets Per 180 DAYS.

Other exampleBelimumab subcutaneous 200 mg — Dispensing Limit = 4 Syringes Per 28 DAYS.

Formulation-specific limitsLimits are specified per product and form (tablets, mLs, syringes, kits).

inv-81: BG = Generic and Brand; B = Brand Only; G = Generic only — formulary availability codes.

BG = Generic and BrandIndicates both generic and brand versions are available/covered for the product entry.

B = Brand OnlyIndicates only brand product is covered or listed for the product entry.

G = Generic onlyIndicates only generic versions are covered or listed for the product entry.

inv-82: Quantity limit per specified time window applied to outpatient pharmacy fills (e.g., Per 30 DAYS, Per 90 DAYS, Per 180 DAYS).

Quantity limit windowQuantity limits are expressed per specified time windows used for outpatient pharmacy fills (examples: Per 30 DAYS, Per 84 DAYS, Per 180 DAYS).

Common periodsMost products use Per 30 DAYS; biologics and pens often use Per 28 DAYS; some topical or specialty items use 56/90/180/365 day windows.

Effect on refill cadenceThe time window determines allowable refill frequency and maximum covered quantity during that period.

inv-83: BG = Generic and Brand; B = Brand only; G = Generic only — BG/B/G indicators.

BG = Generic and BrandEntry flag meaning: both generic and brand available/covered.

B = Brand onlyEntry flag meaning: brand product only is covered/listed.

G = Generic onlyEntry flag meaning: generic product only is covered/listed.

inv-84: BG / B / G — BG/B/G flags indicate Generic and Brand (BG), Brand Only (B), Generic only (G) access designations for each listed product.

BG / B / G meaningBG/B/G flags indicate Generic and Brand (BG), Brand Only (B), or Generic only (G) access designations for each listed product entry.

Examples in listImiquimod 2.5% Zyclara Pump shows B; imiquimod 5% shows G in product entries.

Applied per SKUDesignations are applied at the product/strength/formulation line to guide coverage and substitution.

inv-85: cumulative across agents — quantities for certain topical agents are combined across therapeutically related products when applying limits.

Cumulative applicationSome topical and other agent limits are cumulative across therapeutically related products (e.g., clobetasol, desoximetasone entries indicate cumulative grams/mLs across agents).

ExampleClobetasol propionate cream 0.025% — 100 Grams Per 30 DAYS, 100/30 cumulative across agents.

ImplicationCumulative limits mean quantities across multiple formulations of the same agent count toward the same limit during the period.

inv-86: formulary designation — Generic and Brand (BG); Brand Only (B); Generic only (G).

Formulary designationFormulary designation codes: BG = Generic and Brand; B = Brand Only; G = Generic only (indicates availability for each listed product).

UsageUsed alongside dispensing limits to indicate which product versions are eligible for coverage.

ExampleDesogestrel & ethinyl estradiol entries include BG/B flags with specified tablet-per-days limits.

inv-87: Product designation — BG, B, G.

Product designationProduct lines in the list use shorthand designation values: BG, B, G to indicate formulary availability for each product entry.

ExampleOlanzapine 7.5 mg (Zyprexa) — Dispensing Limit = 60 Tablets Per 30 DAYS; designation = BG.

Operational noteThe designation accompanies each product/strength line to guide claims processing.

inv-88: Dispensing limit — specified quantity per specified days (e.g., 30 Tablets Per 30 DAYS).

Format exampleDispensing limits are presented as a specified quantity per specified days (e.g., '30 Tablets Per 30 DAYS').

Multiple unit typesLimits may be expressed in tablets, blisters, inhalers, mLs, syringes, pens, cartridges, packs, etc., per the time window.

SampleFluticasone furoate entries: 60 Blisters Per 30 DAYS; some inhalers listed as 1 Inhaler Per 30 DAYS.

inv-89: Formulary status flags — BG/B/G.

Formulary status flagsBG, B, G — used throughout product entries to indicate Generic/Brand availability and guide coverage decisions.

Applied per itemFlags accompany each product/strength/formulation line in the dispensing limits list.

Claims impactFlags inform whether a generic substitution is allowed or the brand is required for coverage when limits are enforced.

inv-90: Dispensing Limit — quantity allowed over specified time (e.g., per 30 DAYS, per 84 DAYS).

Dispensing Limit (concise)Maximum quantity of a product allowed over a specified time (examples in the list: Per 30 DAYS, Per 84 DAYS, Per 180 DAYS).

Representative entriesExamples include 1 Inhaler Per 30 DAYS; 3 Injection Devices Per 84 DAYS; 2 Bottles Per 180 DAYS.

UseUsed to determine covered quantity and refill scheduling in pharmacy benefit adjudication.

inv-91: Dispensing Limit definition — the maximum quantity of a specific product allowed for dispensing within a stated time period.

Definition (explicit)Dispensing Limit — the maximum quantity of a specific product allowed for dispensing within a stated time period (e.g., Per 28 DAYS, Per 30 DAYS, Per 180 DAYS).

Member impactMembers prescribed above the limit may obtain excess supply but are liable for costs beyond what the plan covers.

VariationLimits may differ by product, plan, or state regulation; check plan materials for applicability.

inv-92: BG/B/G — indicates whether product is listed as Generic and Brand (BG), Brand Only (B), or Generic only (G).

BG/B/G meaningIndicates whether product is listed as Generic and Brand (BG), Brand Only (B), or Generic only (G).

ConsistencyThese flags are used consistently across product lines to denote formulary availability.

ExamplesMultiple biologic and specialty product lines include B or BG flags in the list.

inv-93: dispensing limit — Dispensing Limit / QL cumulative.

Dispensing limit typesListings include discrete dispensing limits and notes indicating QL (quantity limit) cumulative rules across agents or product families.

Example cumulativeInsulin syringes — Dispensing Limit = 300 Units Per 30 DAYS, QL cumulative across insulin syringes.

Operational effectCumulative QLs aggregate multiple SKUs when enforcing maximum covered quantity for the period.

inv-94: formulary status — Brand/Generic indicators where BG = Generic and Brand, B = Brand only, G = Generic only.

Formulary status summaryBrand/Generic indicators (BG, B, G) denote whether both branded and generic products are allowed, only brand is allowed, or only generic is allowed for each listed item.

Applied in listEach product/strength/formulation line includes one of these indicators to clarify coverage availability.

ExamplesMany biologic entries show B; many oral agents show BG or G as appropriate.

inv-95: BG/B/G indicates Generic and Brand (BG); Brand Only (B); Generic only (G) designation for each drug entry.

BG/B/G indicator useBG/B/G indicates whether Generic and Brand (BG), Brand Only (B), or Generic only (G) designation applies to each drug entry in the list.

ExampleOlanzapine 7.5 mg (Zyprexa) is flagged BG with a 60 Tablets Per 30 DAYS limit.

PurposeUsed to determine allowable product substitution and coverage when applying dispensing limits.

inv-96: the maximum quantity of a drug that may be dispensed in the stated time period (e.g., Tablets Per 30 DAYS).

Maximum quantity (example)Metformin ER 1000 mg — Dispensing Limit = 60 Tablets Per 30 DAYS (example of Tablets Per 30 DAYS format).

DefinitionSpecifies the maximum units (tablets, mLs, syringes, etc.) of a drug that can be dispensed within the stated time period.

Claim impactPharmacy claims are adjudicated against this maximum; quantities beyond it may be payable by the member.

inv-97: designation indicating whether generic and/or brand product is allowed (BG = generic and brand; B = brand only; G = generic only).

Designation meaningBG = generic and brand allowed; B = brand only; G = generic only — indicates whether generic and/or brand product is allowed for each listed entry.

ExamplesAdalimumab entries include B for brand-only designation in many pen/syringe/kit lines.

Applied per SKUDesignation appears alongside each product/strength/formulation in the dispensing list to guide coverage.

inv-98: Maximum quantity of a specific product that may be dispensed within the stated time period (e.g., Tablets Per 30 DAYS).

Maximum quantity (concise)Maximum quantity of a specific product that may be dispensed within the stated time period (e.g., '30 Tablets Per 30 DAYS' shown for resmetirom).

ExampleResmetirom 100 mg — Dispensing Limit = 30 Tablets Per 30 DAYS.

PresentationLimits are listed per product and strength in uniform 'quantity Per days' format across the document.

inv-99: Formulary availability: BG = Generic and Brand, B = Brand Only, G = Generic Only.

Formulary availabilityBG = Generic and Brand; B = Brand Only; G = Generic Only — used to indicate which versions are available for each product line.

Claims guidanceThese flags are used with dispensing limits to adjudicate pharmacy claims and determine allowable substitutions.

Per-entry applicationEach drug/strength/formulation line in the list includes one of these flags.

inv-100: Generic and Brand (BG); Brand Only (B); Generic only (G).

BG / B / G (summary)BG = Generic and Brand; B = Brand Only; G = Generic only — formulary status indicators accompanying dispensing limit entries.

PurposeIndicates allowable product types for coverage when limits are enforced.

Document usageApplied consistently across the dispensing limits list to clarify coverage status per SKU.

inv-101: Formulary status flags indicating Generic and Brand availability (BG = Generic and Brand; B = Brand only; G = Generic only).

Formulary status flagsBG = Generic and Brand; B = Brand only; G = Generic only — flags used to indicate product availability and coverage per entry.

Operational noteFlags accompany each dispensing limit line to guide adjudication and substitution decisions.

Example entriesInhaler and biologic entries in the list use BG/B/G flags to denote availability.

abacavir sulfate soln 20 mglml (Ziagen)	Dispensing Limit = 960 mLs Per 30 DAYS; Brand/Generic designation = BG
abacavir sulfate tab 300 mg (Ziagen)	Dispensing Limit = 60 Tablets Per 30 DAYS; Brand/Generic designation = BG
abacavir sulfate-lamivudine tab 600-300 mg (Epzicom)	Dispensing Limit = 30 Tablets Per 30 DAYS; Brand/Generic designation = BG

OpenPayer

Performance Select Dispensing Limits (DL)

Dispensing Limits and Coverage Criteria

Coding and Formulary Indicators

Provider Impact and Actionable Notes

Definitions and Legend