Blue Cross Blue Shield NM dispensing limits

inv-01: General dispensing and coverage rules — Dispensing limits and applicability

Covered dispensing limits and applicability rules:

Dispensing limits specify the maximum quantity of a listed product allowed per the stated time period (e.g., '30 Tablets Per 30 DAYS').

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

Some dispensing limits apply across multiple medications within a drug class (cumulative QL) as noted for certain topical agents and oral triptans.

Dispensing limits and whether they apply to Brand (B), Generic (G) or Both (BG) are shown for each product; availability may vary by plan or state.

Certain categories (e.g., specialty medications) may be limited to a 30-day supply depending on the member's benefit plan; verify plan materials for exceptions.

inv-02: Sample biosimilar dispensing limits — Examples of product-specific limits (partial list)

Sample biosimilar/adalimumab dispensing limits (partial examples):

Adalimumab auto-injector kit (Humira pen): Dispensing Limit = 1 Kit Per 180 DAYS; designation = B.

Adalimumab auto-injector kit 40 mg/0.4ml (Humira Pen): Dispensing Limit = 2 Pens Per 28 DAYS; designation = B.

Adalimumab-adaz soln auto-injector (Hyrimoz sensoready pens): Dispensing Limit = 2 Pens Per 28 DAYS; designation = B.

Adalimumab-aqvh / Amjevita and many other adalimumab biosimilars: typical Dispensing Limit = 2 Pens or 2 Syringes Per 28 DAYS; designation frequently = B.

inv-03: Example dispensing rules — Per-product dispensing limits and brand/generic designations (examples extracted from this segment)

Example per-product dispensing rules and BG/B/G designations (selected lines):

adalimumab-atto soln prefilled syringe 20 mg/0.4ml (Amjevita): Dispensing Limit = 2 Syringes Per 28 DAYS; designation = B.

adalimumab-bwwd soln auto-injector 40 mg/0.4ml (Hadlima Pushtouch): Dispensing Limit = 2 Pens Per 28 DAYS; designation = B.

adalimumab-fkjp auto-injector kit 40 mg/0.8ml (Hulio / Adalimumab-Fkjp): Dispensing Limit = 2 Pens Per 28 DAYS; designation = B.

adapalene pads 0.1%: Dispensing Limit = 28 Pads Per 28 DAYS; designation = B.

amcinonide cream/lotion/ointment 0.1%: Dispensing Limit = 100 Grams Per 30 DAYS (cumulative across agents); designation = B.

inv-04: Dispensing limits table (excerpt) — Per-product dispensing limits and permitted product types (brand/generic/both).

Excerpt of dispensing limits table showing product, limit and permitted product types:

amphetamine-dextroamphetamine cap er 24hr 37.5 mg (Mydayis): Dispensing Limit = 30 Capsules Per 30 DAYS; permitted = BG.

amphetamine-dextroamphetamine tab 10 mg (Adderall): Dispensing Limit = 60 Tablets Per 30 DAYS; permitted = BG.

amphetamine-dextroamphetamine tab 20 mg (Adderall): Dispensing Limit = 90 Tablets Per 30 DAYS; permitted = BG.

anakinra prefilled syringe 100 mg/0.67ml (Kineret): Dispensing Limit = 28 Syringes Per 28 DAYS; permitted = B.

apixaban tab 5 mg (Eliquis): Dispensing Limit = 74 Tablets Per 30 DAYS; permitted = B.

inv-05: Dispensing limits and availability — Dispensing limits and brand/generic availability designations for listed drugs.

Selected dispensing limits and availability flags with notes where applicable:

azilsartan medoxomil tab 80 mg (Edarbi): Dispensing Limit = 30 Tablets Per 30 DAYS; availability = B.

azithromycin tab 250 mg (Zithromax Z-Pak): Dispensing Limit = 60 Tablets Per 180 DAYS; QL cumulative across strengths; availability = BG.

aztreonam lysine inhalation 75 mg (Cayston): Dispensing Limit = 1 Kit Per 56 DAYS; availability = B.

baclofen oral soln 5 mg/5ml (Baclofen / Ozobax): Dispensing Limit = 2400 mLs Per 30 DAYS; availability = BG.

c1 esterase inhibitor (Haegarda) subcutaneous inj 2000 unit: Dispensing Limit = 27 Vials Per 28 DAYS; availability = B; note = QL calculation based on CDC 90th percentile weight (see Special Clinical Criteria Table).

inv-06: Product dispensing rules — Per-product dispensing rule nodes

Per-product dispensing rule entries (selected examples):

cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (Cometriq) kit: Dispensing Limit = 1 Kit Per 28 DAYS; source preference = B.

cabozantinib s-malate tab 20 mg (Cabometyx): Dispensing Limit = 30 Tablets Per 30 DAYS; source preference = B.

calcipotriene foam 0.005%: Dispensing Limit = 120 Grams Per 30 DAYS; source preference = B.

calcipotriene-betamethasone dipropionate oint 0.005-0.064% (Taclonex): Dispensing Limit = 120 Grams Per 30 DAYS; source preference = BG.

continuous blood glucose system sensor (Dexcom g6/g7; Freestyle Libre variants): Dispensing Limit = 3 Sensors Per 30 DAYS; source preference = B.

inv-07: Dispensing limits and brand/generic stance — Per-product dispensing limits and brand/generic designations (examples from excerpt):

Additional per-product examples showing dispensing limits and brand/generic stance:

continuous glucose system receiver: Dispensing Limit = 1 Receiver Per 365 DAYS; designation shown as B.

continuous glucose system transmitter (Dexcom g6): Dispensing Limit = 1 Transmitter Per 90 DAYS; designation = B.

crizotinib cap 200 mg (Xalkori): Dispensing Limit = 120 Capsules Per 30 DAYS; designation = B.

cromolyn sodium soln nebu 20 mg/2ml: Dispensing Limit = 240 mLs Per 30 DAYS; designation = G.

desoximetasone topical products: Dispensing Limit = 100 g or 90 g or 100 mLs Per 30 DAYS; noted as 100/30 cumulative across agents; designations vary (BG/B per line).

inv-08: sample_product_limits — Product-level dispensing limits (examples extracted from this section)

Sample product-level dispensing limits (selected examples):

dexmethylphenidate hcl cap er 24 hr 20 mg (Focalin Xr): Dispensing Limit = 30 Capsules Per 30 DAYS; brand/generic = BG.

dextroamphetamine sulfate cap er 24hr 10 mg (Dexedrine): Dispensing Limit = 120 Capsules Per 30 DAYS; brand/generic = BG.

dulaglutide soln auto-injector (Trulicity): Dispensing Limit = 4 Pens Per 28 DAYS; fill limit of one injectable GLP-1 agent and one strength per 28 days applies; brand/generic = B.

dupilumab subcutaneous soln auto-injector 200 mg/1.14ml (Dupixent): Dispensing Limit = 2 Pens Per 28 DAYS; brand/generic = B.

inv-09: product_quantity_limits — Per-product dispensing limits and brand/generic status (examples from this segment)

Representative per-product quantity rules (examples):

elagolix-estradiol-norethindrone cap pack (Oriahnn): Dispensing Limit = 56 Capsules Per 28 DAYS; designation = B.

elbasvir-grazoprevir tab 50-100 mg (Zepatier): Dispensing Limit = 30 Tablets Per 30 DAYS; designation = B.

eletriptan hydrobromide tab 20 mg (Relpax): Dispensing Limit = 18 Tablets Per 30 DAYS; quantity limit for oral triptans is cumulative across agents with a maximum of 18 tablets per 30 days; designation = BG.

inv-10: Dispensing limits list — Dispensing limits and brand/generic designation for listed products. Each line indicates product, formulation/strength, dispensing limit ...

Dispensing limits list (each line: product, formulation/strength, dispensing limit, availability code) — partial extract:

estradiol transdermal patches (various): Dispensing Limit = 30 Patches Per 30 DAYS; availability codes vary (BG/B).

follitropin alfa products (Gonal-F) various presentations: Dispensing Limits = multiple vials/pens per 30 DAYS as listed (e.g., 5 Vials Per 30 DAYS; 10 Pens Per 30 DAYS); availability = B.

follitropin beta cartridges/pens: Dispensing Limits specified per 30 DAYS with per-cartridge billing notes; availability = B.

inv-11: product-specific dispensing criteria — Per-drug dispensing limits and brand/generic applicability shown as policy rules for reimbursement/dispensing.

Product-specific dispensing criteria (selected rules):

fluticasone-salmeterol inhal aerosol 230-21 mcg/act (Advair Hfa): Dispensing Limit = 1 Inhaler Per 30 DAYS; brand/generic = B.

follitropin alfa for inj 1050 unit (Gonal-F): Dispensing Limit = 5 Vials Per 30 DAYS; brand/generic = B.

fremanezumab-vfrm subcutaneous soln auto-inj 225 mg/1.5ml (Ajovy): Dispensing Limit = 3 Injection Devices Per 84 DAYS; brand/generic = B; note = 4.5 mL = 3 auto-injectors.

gabapentin (once-daily) tab 600 mg (Gralise): Dispensing Limit = 90 Tablets Per 30 DAYS; brand/generic = BG.

inv-12: Product dispensing limits — Per-product dispensing rules (quantity and allowed formulation type).

Product dispensing limits (quantity and allowed formulation type) — examples:

imatinib mesylate tab 100 mg (Gleevec): Dispensing Limit = 90 Tablets Per 30 DAYS; designation = BG.

insulin aspart (Fiasp) solutions and pens: Dispensing Limit = 100 mLs Per 30 DAYS for many formulations; designation typically = B.

infliximab-dyyb prefilled syringe kits 120 mg/ml (Zymfentra): Dispensing Limit = 2 Syringes Per 28 DAYS; designation = B.

inv-13: Dispensing quantity limits — Quantity limits applied per 30 days by product or product group as listed below.

Quantity limits applied per 30 days by product group (examples):

Insulin solutions and pens (multiple brands and biosimilars): Dispensing Limit = 100 mLs Per 30 DAYS (common across many lispro and lispro‑protamine entries).

Insulin pen needles: Dispensing Limit = 300 Insulin Pen Needles Per 30 DAYS; quantity limit is cumulative across all pen needle SKUs listed.

Insulin syringes: Dispensing Limit = 300 Syringes Per 30 DAYS; QL cumulative across all insulin syringe SKUs.

Afrezza inhalation cartridges: Dispensing Limits vary by cartridge strength with specific per-30-day cartridge maximums (examples shown in the table).

inv-14: Product dispensing criteria — Product-specific dispensing limits and brand/generic designation entries (partial list — document is a longer table).

Partial product dispensing criteria (selected entries):

Insulin syringe/needle U-100 various gauges: Dispensing Limit = 300 Syringes Per 30 DAYS; QL cumulative across all insulin syringes; designation shown as B.

interferon beta- (Betaseron): Dispensing Limit = 14 Vials Per 28 DAYS; designation = B.

interferon beta-1a (Rebif) syringes/prefilled: Dispensing Limit = 12 Syringes Per 28 DAYS; QL cumulative across strengths; designation = B.

ivacaftor (Kalydeco) packets/tabs: Dispensing Limit = 60 Packets/Tablets Per 30 DAYS; designation = B.

isotretinoin (Absorica) various strengths: Dispensing Limit = 60 Capsules Per 30 DAYS; designation = BG or B depending on strength.

inv-15: Selected coverage criteria (partial list) — Dispensing limits and allowed product types for listed medications.

Selected coverage criteria with dispensing limits and allowed product types (partial):

lebrikizumab-lbkz 250 mg/2ml auto-inject (Ebglyss): Dispensing Limit = 1 Pen Per 28 DAYS; brand flag = B.

ledipasvir-sofosbuvir (Harvoni) various forms: Dispensing Limit = 28 Packs/Tablets Per 28 DAYS; brand flag = B.

liraglutide solution pen-injector (Victoza): Dispensing Limit = 3 Pens Per 30 DAYS; note = Fill limit of one injectable GLP-1 agent and one strength per 28 days; refill window applies; brand flag = BG.

lidocaine topical products: Dispensing limits shown (e.g., 120 Each Per 30 DAYS or specified grams/mL); note = quantity limit cumulative across formulations; brand flag varies by formulation.

inv-16: Partial per-drug dispensing limits and designations — Per-product dispensing limits and brand/generic designation (partial list):

Partial list of per-drug dispensing limits and BG/B/G designations (examples):

lisdexamfetamine dimesylate chew tab 20 mg (Vyvanse): Dispensing Limit = 30 Tablets Per 30 DAYS; designation = BG.

lisinopril oral solution 1 mg/ml (Qbrelis): Dispensing Limit = 2400 mLs Per 30 DAYS; designation = B.

lonafarnib cap 50 mg (Zokinvy): Dispensing Limit = 120 Capsules Per 30 DAYS; designation = B.

liraglutide soln pen-injector (Victoza): Dispensing Limit = 3 Pens Per 30 DAYS; designation = BG; note = one injectable GLP-1 agent and one strength per 28 days fill limit applies.

Product Identification and Coding Notes

Sample drug dispensing entriesNDC

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

Adalimumab biosimilarsNDCCovered

Adalimumab auto-injector kit (Humira pen), Dispensing Limit = 1 Kit Per 180 DAYS; Adalimumab auto-injector kits/pens/syringes (various biosimilars) Dispensing Limit = 2 Pens or 2 Syringes Per 28 DAYS

Drug-level dispensing limits (excerpt)mixed

Product-name based entries with quantity limits and BG/B/G designation; no CPT/HCPCS/NDC billing codes provided in this excerpt.

Drug-level dispensing limits (no procedure codes)mixed

Drug name and dispensing limit entries (e.g., azithromycin tab 250 mg (Zithromax Z-Pak), Dispensing Limit = 60 Tablets Per 180 DAYS; QL cumulative across strengths) — no billing codes provided in this excerpt.

Drug list (no procedure codes)mixed

Product and package-based dispensing limits (e.g., cabozantinib kit 1 Kit Per 28 DAYS; calcifediol cap ER 60 Capsules Per 30 DAYS) with brand/generic flags; no procedure codes provided.

Product identification (name/strength/form)mixed

Products identified by name/strength/form only (e.g., continuous glucose system receiver, Dispensing Limit = 1 Receiver Per 365 DAYS; crizotinib cap 200 mg, Dispensing Limit = 120 Capsules Per 30 DAYS) — no CPT/HCPCS/NDC codes provided in these chunks.

Brand/Generic flagsmixed

BG	Generic and Brand
B	Brand Only
G	Generic Only

Codes not providedmixed

No CPT/HCPCS/NDC/ICD codes are listed in this segment (product-level dispensing limits shown by name/strength/form).

Dispensing lines (no codes present)NDC

Drug/formulation lines with dispensing limits and BG/B/G availability codes; no billing codes (NDC/HCPCS) present in this extract.

NDC/drug-level dispensing rules (implicit)NDC

Drug-level dispensing quantities and brand/generic applicability shown by product (e.g., glatiramer acetate prefilled syringe 20 mg/ml, Dispensing Limit = 30 Syringes Per 30 DAYS) — implicit NDCs not provided.

NDC/Product-levelNDC

Product entries list dispensing limit and allowed product type (e.g., iloperidone tab 8 mg, Dispensing Limit = 60 Tablets Per 30 DAYS) with brand/generic designation; no explicit billing codes included.

Product descriptions onlymixed

Insulin product entries identified by description with dispensing limits (e.g., insulin lispro pen-injector 100 unit/ml, Dispensing Limit = 100 mLs Per 30 DAYS); no HCPCS/CPT/NDC billing codes shown in these excerpts.

NDC/Product-level dispensing entriesNDC

Insulin syringes/needles listed with Dispensing Limit = 300 Syringes Per 30 DAYS; QL cumulative for all insulin syringes — entries are product-level, no procedure codes provided.

Drug dispensing entriesmixed

Entries include medication name, strength/form, dispensing limit and BG/B/G flag (e.g., lebrikizumab auto-inject 250 mg/2 ml, Dispensing Limit = 1 Pen Per 28 DAYS; lenacapavir tab 300 mg, Dispensing Limit = 4 Tablets Per 365 DAYS). No billing codes provided.

Drug list (no codes)mixed

Product-level dispensing limits listed by drug name/strength/form (e.g., lisdexamfetamine chew tabs 20–60 mg, Dispensing Limit = 30 Tablets Per 30 DAYS); no CPT/HCPCS/ICD-10/NDC codes provided.

common dispensing period — 30 DAYS (many entries) or 28/180 DAYS for select products

Common dispensing periodPer 30 DAYS is the most common dispensing period across entries; some products use Per 28 DAYS or longer windows (e.g., 180 DAYS)

Example 28-day windowsMany biologic injectables and pens/syringes use Per 28 DAYS (e.g., adalimumab products: 2 Syringes/Pens Per 28 DAYS)

Longer windowsSelect kits and specialty items use longer windows such as Per 180 DAYS or Per 365 DAYS (documented for some kits and annual supplies)

Per-product dispensing limit — Examples

Per-product examples2 Syringes / 28 DAYS for many adalimumab products (e.g., Amjevita, Hadlima)

Oral tablet example30 Tablets Per 30 DAYS for many oral medications (e.g., cabozantinib tabs, azilsartan)

Topical/cream example100 Grams Per 30 DAYS for certain topical corticosteroids (e.g., desoximetasone; diflorasone diacetate)

Per-30-day limit commonality

Primary time unitMost dispensing limits are expressed Per 30 DAYS (typical for tablets, liquids, and many injectables)

Other time unitsPer 28 DAYS is common for pens/syringes and some biologics; Per 56, 84, 90, 180 or 365 DAYS used for select products

Device/supply windowsDurable/device items may use annual windows (e.g., 1 Receiver Per 365 DAYS) or Per 90 DAYS for transmitters

example dispensing limit format — e.g., 30 Tablets Per 30 DAYS or 1 Kit Per 56 DAYS

Tablet format example30 Tablets Per 30 DAYS (e.g., cabozantinib tab 20 mg)

Kit example1 Kit Per 28 DAYS (e.g., cabozantinib Cometriq kits)

Inhaler example1 Inhaler Per 30 DAYS (e.g., fluticasone-salmeterol inhal aerosol)

common tablet limit — 30-120 tablets per 30 days depending on product

Tablet rangeCommon tablet limits range from 30 to 120 Tablets Per 30 DAYS depending on product (examples: 30, 60, 90, 120)

Lower tablet examples30 Tablets Per 30 DAYS (many oral agents such as abemaciclib, cabozantinib)

Higher tablet examples120 Tablets Per 30 DAYS for some agents (e.g., certain oral oncology or high-count formulations)

Per-period dispensing limits — Various (examples)

Single-year example4 Tablets Per 365 DAYS for lenacapavir (Yeztugo/Sunlenca examples) or 4 Tablets Per 365 DAYS noted in document

Shorter windows examples1 Per 365 DAYS (receivers), 1 Per 90 DAYS (transmitters), 120 Capsules Per 30 DAYS (some agents)

Cumulative topical limit100 Grams Per 30 DAYS for certain topical agents; cumulative limits may apply across agents (e.g., 100/30 cumulative)

diflorasone diacetate cream cumulative limit — 100 Grams Per 30 DAYS; 100/30 cumulative across agents

Diflorasone cream limit100 Grams Per 30 DAYS for diflorasone diacetate cream/ointment (Apexicon E); 100/30 cumulative across agents

Alternate formulation noteDiflorasone oint 0.05% also listed as 180 Grams Per 90 DAYS for some entries

Cumulative policyTopical corticosteroid quantities are sometimes cumulative across similar agents as noted in entries

common_time_units — Dispensing limits expressed per 28 or 30 days

Primary time unitsDispensing limits are commonly expressed Per 28 DAYS or Per 30 DAYS (examples include 56 per 28 days and 30 per 30 days)

ExamplesMany kits and pens use Per 28 DAYS; many tablets use Per 30 DAYS

Longer windowsOther windows (56, 84, 90, 180, 365 days) also appear for specific products

annual limit example — 1080 Tablets Per 365 DAYS for ferric citrate 1 gm (Auryxia)

Annual tablet example1080 Tablets Per 365 DAYS stated as an annual example for ferric citrate 1 gm (Auryxia) in document

Other annual examplesLenacapavir entries show 4 Tablets Per 365 DAYS for certain therapy packs

Usage noteSome specialty agents use annual or multi‑month windows to reflect dosing schedules

maximum tablets/30 days (example) — 90 (e.g., gabapentin 600 mg = 90 tablets per 30 DAYS)

Maximum tablets per 30 days (example)90 Tablets Per 30 DAYS for gabapentin 600 mg (Gralise) as listed

Other tablet maximaSome strengths/formulations show 60 or 120 tablets per 30 days depending on product

ContextTablet maxima vary by strength and formulation as reflected in multiple entries

Common quantity threshold — 100 mLs per 30 DAYS for many insulin formulations

Common insulin volume threshold100 mLs Per 30 DAYS is the typical quantity limit for many insulin solutions and pen cartridges

Examples of productsInsulin lispro, lispro protamine combos, and multiple pen/cartridge formats are listed at 100 mLs Per 30 DAYS

ExceptionsSome insulin inhalation cartridges (Afrezza) list much larger cartridge counts per 30 days varying by strength

per_30_day_limits — Examples: 100 mLs for many insulin solutions/pens; 300 pen needles or syringes; cartridge limits vary

Insulin solutions/pens100 mLs Per 30 DAYS for many insulin pen/solution products (document lists multiple brands and biosimilars)

Pen needles/syringes300 Insulin Pen Needles Per 30; QL cumulative across all pen needle SKUs; 300 Syringes Per 30 DAYS for insulin syringes (cumulative)

Cartridge variabilityAfrezza cartridges and similar inhalation cartridges list strength‑specific per‑30‑day maximums (examples include 1260, 2520 cartridges per 30 DAYS)

Quantity limits per time period — Examples

Syringes/pen needles examples300 Syringes or Pen Needles Per 30 DAYS (cumulative across types); some interferon products list 12 Syringes Per 28 DAYS

Kit limits1 Kit Per 28 DAYS or 1 Kit Per 180 DAYS for various injectable kits and titration packs

28-day syringe example12 Syringes Per 28 DAYS for certain interferon beta-1a (Rebif) prefilled syringes

Maximum dispensing windows shown — Per 21, 28, 30, 180, 365 day windows

Dispensing windows listedDocument shows maximum dispensing windows including Per 21, Per 28, Per 30, Per 90, Per 180 and Per 365 day windows

Frequent windowsPer 30 DAYS and Per 28 DAYS appear most frequently across entries

Special windowsSome products use unique windows (e.g., 112 DAYS for cenegermin vials; 365 DAYS for receivers)

dispensing limit time window — Per 30 DAYS (many entries); some exceptions per 28 or 90 DAYS or per 42 DAYS

Typical time windowPer 30 DAYS is the default/time window for many dispensing limits

Common exceptionsSome injectables and pens use Per 28 DAYS; device components may use Per 90 or Per 365 DAYS

Product-specific noteGLP-1 injectable fill limits reference a 28-day fill window and refill rules

What Pharmacies and Providers Must Know

Denial Risk

Member cost responsibility for quantities beyond limits

If a prescription exceeds a stated dispensing limit the member may still obtain the medication but will be responsible for the full cost of quantities beyond the coverage limit. Verify member-specific plan materials or call the number on the back of the member ID card for coverage exceptions, state variations, or mail-service restrictions.

Member cost responsibility applies when prescriber authorizes a quantity beyond the listed dispensing limit.

Note

Special Clinical Criteria reference

See the Special Clinical Criteria table for details on QL calculations and clinical assumptions used to set quantity limits for certain agents — for example, c1 esterase inhibitor (Haegarda) QL calculations reference CDC 90th percentile weight assumptions and rounding to even doses to reduce waste.

Special Clinical Criteria table contains QL calculation notes and weight/ IU assumptions for C1 esterase inhibitor (Haegarda).

Billing Rule

Durable/Device dispensing limits

Durable medical device and continuous glucose monitoring components have specific dispensing windows and limits. Confirm manufacturer/model when adjudicating and adhere to the annual/90‑day/30‑day windows below.

Continuous glucose system receiver: 1 receiver per 365 days (examples: Dexcom G6 receiver, Dexcom G7 receiver, Freestyle Libre receivers).
Continuous glucose system transmitter (Dexcom G6 transmitter): 1 transmitter per 90 days.

Billing Rule

Dispensing limits listing

This section lists per-product dispensing limits and whether Brand (B), Generic (G) or both (BG) are allowed. Limits are expressed as quantity per time window (for example, per 28 days, per 30 days, per 84 days, per 365 days). Use the per-product entries when adjudicating claims; some limits are cumulative across related formulations.

Per-product dispensing limits are applied as listed (e.g., many oral tablets = X tablets per 30 days; many biologic auto-injectors = Y pens/syringes per 28 days).
Some items include multi-month dispensing (e.g., fremanezumab: 3 devices per 84 days).
Brand/generic designation (B/G/BG) is listed per product and must be respected when plan restricts to brand or generic only.

Billing Rule

Cumulative quantity note

Several topical and formulation groups have cumulative quantity limits across agents — when multiple formulations of the same active or therapeutic class are dispensed, apply the cumulative cap across those agents.

Desoximetasone products: 100 grams OR 100 mL per 30 days cumulative across desoximetasone cream/gel/ointment/spray agents.
Fluocinonide/desoximetasone topical categories: cumulative caps (example: fluocinonide ointment 90 g per 30 days with 100/30 cumulative across agents).
Lidocaine topical formulations: quantity limits cumulative across formulations (example: 120 each per 30 days cumulative).

Billing Rule

Multi-month dispensing limits

Some biologics and specialty products are dispensed on multi-month schedules. Apply the multi‑month limits as specified rather than converting to monthly prorations.

Fremanezumab (Ajovy) auto-injectors or prefilled syringes: 3 injection devices or syringes per 84 days.
Iloperidone titration packs: 1 pack per 180 days (each pack type listed).

Billing Rule

Per‑product dispensing limits (examples)

Examples of per‑product dispensing limits (not exhaustive): many oral and specialty agents are limited to a specific number of tablets/capsules per 28/30 days; biologic pens/syringes are commonly limited per 28 days; specialty cartridges and kits have kit-based limits per 28 days.

Cabozantinib (Cabometyx) 20/40/60 mg tablets: 30 tablets per 30 days. Cabozantinib kits (Cometriq): 1 kit per 28 days.
Dulaglutide (Trulicity) pens: 4 pens per 28 days (fill limit = one injectable GLP-1 agent and one strength per 28 days; refill window applies).
Evolocumab (Repatha) prefilled syringe 140 mg/ml: 6 syringes per 28 days; cartridge Pushtronex: 2 cartridges per 30 days.

Billing Rule

Pen needle and insulin syringe cumulative QLs

Insulin pen needles and insulin syringes have cumulative quantity limits that apply across all pen-needle or syringe SKUs. Ensure cumulative counts are enforced regardless of specific brand or pack-size dispensed.

Insulin pen needles: 300 pen needles per 30 days; QL cumulative across all pen needle SKUs.
Insulin syringes: 300 syringes per 30 days; QL cumulative across all insulin syringe SKUs.

Billing Rule

Afrezza cartridge QLs

Afrezza inhalation cartridges have specific per‑30‑day maximums that vary by cartridge strength and package configuration. Apply the exact cartridge limits when adjudicating inhaled insulin claims.

Afrezza cartridge examples and limits (select by strength/config): 1260 cartridges per 30 days (60x4 pack), 1080 cartridges per 30 days (90x8 pack), 1800 cartridges per 30 days (90x4 pack), 900 cartridges per 30 days (12 unit cartridge), 2520 cartridges per 30 days (4 unit cartridge), 1260 cartridges per 30 days (8 unit cartridge).

Note

Dispensing limits listing (no authorization instructions)

This listing section contains dispensing limits only and does not supersede separate prior authorization, step therapy, or documentation rules that may apply elsewhere in plan policy. When no authorization/step notes are present in an entry, standard adjudication follows the dispensing limit and brand/generic designation shown.

Entries lacking explicit prior authorization or step therapy notes should be adjudicated using the listed dispensing limit and B/G/BG designation.
Verify other policy sections for any additional utilization management requirements that may apply to a given product.

Terms and Abbreviations

Dispensing limit (definition and implications)

Definition: Dispensing LimitQuantity of covered medication per prescription or in a given time period; quantities beyond the limit may be obtained but are at full member cost.

Brand/Generic flagsBG = Generic and Brand; B = Brand Only; G = Generic Only — used after product entries to indicate applicability

Member responsibilityIf prescribed quantity exceeds the dispensing limit, the member is responsible for costs beyond coverage

BG / B / G designations

BG / B / G meaningBG = Generic and Brand; B = Brand Only; G = Generic Only — indicates whether listing applies to brand, generic, or both

Usage in tableThese designations appear after product entries to indicate permitted product sourcing for the listed dispensing limit

Multiple referencesVarious chunks repeat and use BG/B/G flags across the dispensing list to denote availability

Dispensing Limit — formal definition

Dispensing Limit (formal)Dispensing Limit = maximum quantity of the listed dosage form allowed per specified time period (e.g., '2 Syringes Per 28 DAYS' or '30 Tablets Per 30 DAYS')

Examples in policyMany entries explicitly state 'Dispensing Limit = X Per Y DAYS' alongside product and BG/B/G flags

InterpretationLimits are enforced for coverage; quantities beyond limits may be filled but are member-pay

BG / B / G — usage and placement

BG/B/G usage repeatedBG, B, and G flags are used throughout the product list to denote permitted product types for each dispensing limit entry

Table placementFlags appear after product and dispensing limit in each line (e.g., 'Dispensing Limit = 30 Tablets Per 30 DAYS; BG')

No codes presentEntries are product-based with BG/B/G designations rather than CPT/HCPCS codes in many segments

Cumulative across agents and cumulative QL

Cumulative across agentsSome topical and syringe/needle entries specify QL cumulative across similar agents (e.g., desoximetasone 100/30 cumulative; insulin syringes/pen needles cumulative QL)

Pen needle/syringe cumulative QLPen needles and insulin syringes have QLs cumulative across all listed SKUs (document lists 'QL cumulative across all pen needles' and 'cumulative for all insulin syringes')

Topical cumulative noteTopical corticosteroid grams or mLs are sometimes cumulative across formulations and agents as noted in entries

Quantity limit (QL) cumulative for insulin syringes and pen needles

Pen needle/syringe cumulative QLQL cumulative across all insulin pen needles and insulin syringes (e.g., 300 Per 30 DAYS cumulative)

Document examplesMultiple pen needle and syringe SKUs list '300 Insulin Pen Needles Per 30; QL cumulative across all pen needles' and similar for syringes

ImplicationLimits apply across equivalent syringe/needle products rather than per SKU

Dispensing Limit — table definition and flags

Dispensing Limit (restated)Dispensing Limit = maximum quantity permitted to be dispensed within the specified time period for the listed product (e.g., '30 Tablets Per 30 DAYS')

BG/B/G flagsFlags denote whether Brand only, Generic only, or both are allowed for that dispensing limit

Applied across tableThis structure is consistently applied across the dispensing limits table entries

OpenPayer

Balanced Biosimilar Dispensing Limits (DL)

Dispensing Limits and Coverage Rules

Product Identification and Coding Notes

What Pharmacies and Providers Must Know

Terms and Abbreviations