CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Performance Full Dispensing Limits (Drug Dispensing Limits)

Defines quantity and time-period limits applied to covered prescription drugs for Blue Cross and Blue Shield of Oklahoma members; affects prescribers, pharmacists, and members subject to BCBSOK pharmacy benefits.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPerformance Full Dispensing Limits (Drug Dispensing Limits)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionEnsure pharmacy claims reflect the product-specific dispensing quantity and time-period limits listed in the policy; documentation should support any request to dispense beyond the listed limit.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~120+distinct products listed (excerpt)

30-day / 28-day / 90/180/365common dispensing periods

2 Penscommon adalimumab limit

100 mLstypical insulin liquid limit

300pen needles/syringes cap

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Coverage Criteria — Dispensing Limits

General dispensing limits

Covered subject to specified dispensing limits listed per drug.

Dispensing limit rules: Coverage is provided but limited to the listed quantity per specified time period for each drug; if a prescription exceeds the limit the member may obtain the medication but is responsible for the full cost beyond coverage.per-item limits as listed

Limits vary by drug and may differ by member or state

Dispensing limits

Coverage limited to quantities at or below the listed dispensing limits.

Dispensing limit rule: Coverage/claim payment applies when the dispensed quantity for the listed product does not exceed the 'Dispensing Limit' specified for the named time period (for example, 60 Capsules Per 30 DAYS or 120 Tablets Per 30 DAYS).per-product limits as listed

Each product entry contains exact quantity and period; brand/generic code indicates allowed product source.

Standard dispensing limits

Covered when dispensing does not exceed the listed per-30-day limits for the specific product.

Per-product monthly limit: Dispense each listed insulin and liquid product at or below its specified 'Dispensing Limit' per 30 days (example: 100 mLs Per 30 DAYS for many insulin pen/solution products).see product-specific limit (e.g., 100 mLs per 30 days)

Limits are product- and formulation-specific; inhaled cartridge pack sizes and concentrated insulin products have itemized numeric limits.

Supply cumulative limits

Covered when supply quantities for devices do not exceed cumulative limits.

Pen needles/syringes cumulative limit: The total quantity of insulin pen needles dispensed across all listed SKUs must not exceed 300 per 30 days; the total quantity of insulin syringes across all listed SKUs must not exceed 300 per 30 days.300 per 30 days

Document describes these as 'QL cumulative across all pen needles' and 'QL cumulative for all insulin syringes'.

Dispensing quantity limits

Covered when dispensed at or below the listed dispensing limit for the exact product/strength.

Per-product limits: Each product and strength is covered up to the specified quantity within the stated period listed in the policy (for example, lisdexamfetamine 30 Capsules Per 30 DAYS; lorazepam 150 Tablets Per 30 DAYS).per-item limits as listed

See individual product lines for exact quantity and brand/generic (BG/B/G) designation.

Some plans may apply plan-specific exclusions or restrictions that are not uniformly enforced for all members. The source list notes that some plans may exclude coverage for certain agents or drug categories (for example, erectile dysfunction agents), that availability may vary by mail service, and that dispensing limits may not apply to all members or may vary by state. Members and providers should verify plan-specific coverage or exclusions by consulting plan materials or calling the number on the back of the member ID card.

Certain topical products are governed by a cumulative quantity cap across formulations. For example, desoximetasone topical formulations are listed with 100 Grams Per 30 DAYS and the entries indicate a 100/30 cumulative across agents. Similarly, lidocaine topical/patch/powder/gel entries reference a cumulative limit (examples appear elsewhere in the list). Pharmacies must apply the cumulative cap across the listed topical formulations when adjudicating claims.

The referenced insulin and formulation fragments do not present an explicit list of excluded drugs. Instead, they document product-level dispensing limits (for example, multiple insulin presentations capped at 100 mLs Per 30 DAYS) and brand/generic designations. No product in these chunks is called out as excluded.

This fragment enumerates dispensing limits for multiple products (for example, lisdexamfetamine entries and several specialty agents) but does not explicitly identify drugs as excluded from coverage. The entries list per-product quantity caps and brand/generic flags rather than exclusion statements.

Within the cited sections, items are presented with dispensing limits and brand/generic designations but are not labeled as not medically necessary. The document does not explicitly mark any listed product in these chunks as not medically necessary.

Coding and Quantity Limit Tables

Performance Full Dispensing Limits (DL) — Selected Codesmixed

betamethasone dipropionate augmented cream 0.05%	Dispensing Limit = 100 Grams Per 30 DAYS; 100/30 cumulative across agents. Status = Generic (G).
bimatoprost ophth soln 0.01% (Lumigan)	Dispensing Limit = 2.5 mLs Per 20 DAYS. Status = Brand (B).
bimekizumab-bkzx subcutaneous soln auto-injector 160 mg/ml (Bimzelx)	Dispensing Limit = 2 Pens Per 56 DAYS. Status = Brand (B).
bimekizumab-bkzx subcutaneous soln auto-injector 320 mg/2ml (Bimzelx)	Dispensing Limit = 1 Pen Per 56 DAYS. Status = Brand (B).
bimekizumab-bkzx subcutaneous soln prefilled syr 160 mg/ml (Bimzelx)	Dispensing Limit = 2 Syringes Per 56 DAYS. Status = Brand (B).
bimekizumab-bkzx subcutaneous soln prefilled syr 320 mg/2ml (Bimzelx)	Dispensing Limit = 1 Syringe Per 56 DAYS. Status = Brand (B).
bosentan tab 125 mg (Tracleer)	Dispensing Limit = 60 Tablets Per 30 DAYS. Status = Brand/Generic (BG).
bosentan tab 62.5 mg (Tracleer)	Dispensing Limit = 60 Tablets Per 30 DAYS. Status = Brand/Generic (BG).
bosutinib cap 100 mg (Bosulif)	Dispensing Limit = 150 Capsules Per 30 DAYS. Status = Brand (B).
bremelanotide acet subcutaneous soln auto-inj 1.75 mg/0.3ml (Vyleesi)	(Preserve existing section — entry expected elsewhere in full list).

1–10 of 56

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Performance Full Dispensing Limits (DL) — Brand/Generic Availability Codesmixed

BG	Generic and Brand available
B	Brand only
G	Generic only

Performance Full Dispensing Limits (DL) — Insulin, Pen Needles, Syringes & Pump Supplies (Selected)mixedCovered

insulin aspart inj soln 100 unit/ml (multiple brands)	Dispensing Limit = 100 mLs Per 30 DAYS; Quantity limit cumulative across injectable formulations. Status = Brand (B).
insulin degludec inj/pen 100 unit/ml (Tresiba/Tresiba Flextouch)	Dispensing Limit = 100 mLs Per 30 DAYS; cumulative across injectable formulations. Status = Brand (B).
insulin glargine inj/pen (Lantus/Basaglar/Toujeo/Semglee/Rezvoglar)	Dispensing Limit = 100 mLs Per 30 DAYS; cumulative across injectable formulations. Status = Brand (B).
insulin lispro inj soln 100 unit/ml (Humalog/Admelog/Lyumjev)	Dispensing Limit = 100 mLs Per 30 DAYS. Status = Brand (B).
insulin pen needle entries	Insulin pen needles Dispensing Limit = 300 Pen Needles Per 30 DAYS; QL cumulative across all pen needles. Status = Brand (B).
insulin syringe entries	Insulin syringes Dispensing Limit = 300 Syringes Per 30 DAYS; QL cumulative for all insulin syringes. Status = Brand (B).
insulin infusion disposable pump kit (Omnipod)	Dispensing Limit = 1 Kit Per 720 DAYS. Status = Brand (B).

Performance Full Dispensing Limits (DL) — Performance Full Dispensing Examples / Notesmixed

C1 Esterase QL Note	Calculations for C1 esterase inhibitors based on CDC 90th percentile adult weight averaged to 112.5 kg as documented; see Special Clinical Criteria Table.
Oral Triptan Cumulative Limit	Maximum of 18 tablets per 30 days across all oral triptans and triptan combinations (cumulative).
Common Insulin DL	Per-30-day liquid insulin limit = 100 mLs; pen needles/syringes count limit = 300 per 30 days cumulative across items; pump/device replacement threshold = 1 Kit Per 720 DAYS.

Product-level Quantity Limits (Selected Items)

inv-95: abacavir sulfate soln 20 mg/ml (Ziagen) — 960 mLs

abacavir solution limitabacavir sulfate soln 20 mg/ml (Ziagen) — 960 mLs Per 30 DAYS

Brand/generic designationEntry lists Brand/Generic availability code (BG) for this solution

Claim periodLimit specified explicitly as per 30 days in the product line

inv-96: abacavir sulfate tab 300 mg (Ziagen) — 60

abacavir 300 mg tab limitabacavir sulfate tab 300 mg (Ziagen) — 60 Tablets Per 30 DAYS

DesignationProduct line shows Brand/Generic flag (BG)

Per-period enforcement

Provider / Pharmacy Actions and Enforcement

Billing Rule

Dispensing limits and claims submission

Dispensing limits apply to pharmacy claims and are enforced at point-of-sale. Pharmacists and providers must ensure the dispensed quantity and days' supply on the claim do not exceed the product-specific Dispensing Limit (e.g., "4 Pens Per 28 DAYS" for dulaglutide formulations). Coverage limits may vary by member or state and some limits are cumulative across drug classes (for example, oral triptans are limited to 18 tablets per 30 days across all agents). If a prescriber writes for a quantity that exceeds the Dispensing Limit, the member may still obtain the medication but will be responsible for any cost beyond the coverage limit. Pharmacies must submit claims using the correct product identifier (NDC/brand/generic flag) and reflect the appropriate quantity and days' supply to avoid denials.

Apply per-product Dispensing Limit and period exactly as listed on the formulary.
Cumulative limits must be applied across agents when specified (e.g., oral triptans: max 18 tablets/30 days across all agents).
Claims must use the correct NDC/brand/generic indicator to match the listed Dispensing Limit.
If Dispensing Limit is exceeded at point-of-sale, the claim may be denied or the member may be billed for the excess amount.

Background and Rationale

Dispensing limits are administrative controls placed on covered medications to encourage appropriate use and to cap quantities dispensed per prescription or within a specified time period. The policy explains that limits may be expressed as a maximum quantity per prescription or per time window (for example, per 30 days) and that coverage is provided only up to the listed limit; if a prescription exceeds the limit, the member may still obtain the medication but will be responsible for the full cost beyond coverage. These limits may vary by drug category, member benefits, or state rules and are intended to align dispensing with expected clinical use.

Definitions and Terms

Policy Revision History

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPerformance Full Dispensing Limits (Drug Dispensing Limits)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Dispensing limit enforced as per 30 days per the product entry

inv-97: abaloparatide pen-injector (Tymlos) — 1.56

Tymlos pen volumeabaloparatide pen-injector (Tymlos) — 1.56 mLs Per 30 DAYS (1.56 mLs = 1 injection)

Unit noteEntry specifies the mL equivalent and that 1.56 mLs equals one injection

Brand statusListed as Brand (B) in the product line

inv-98: abatacept prefilled syringes (Orencia) — 4

Orencia syringes per periodabatacept prefilled syringes (Orencia) — 4 Syringes Per 28 DAYS

Multiple presentationsSeveral Orencia presentations list the same 4 syringes per 28-day limit

Brand-only designationListed as Brand (B) for these presentations

inv-99: abemaciclib tabs (Verzenio) — 60

Verzenio tablet capabemaciclib tabs (Verzenio) — 60 Tablets Per 30 DAYS

Multiple strengths same limitVarious strengths of abemaciclib share the 60-per-30-day limit as listed

Brand statusEntries show Brand (B) designation

inv-100: aclidinium bromide inhaler (Tudorza Pressair) — 1

Tudorza inhaler limitaclidinium bromide inhaler (Tudorza Pressair) — 1 Inhaler Per 30 DAYS

Formulation-specificBreath-activated inhaler presentations list the 1 inhaler per 30 days limit

Brand flagListed with Brand (B) designation

inv-101: acyclovir buccal tab 50 mg (Sitavig) — 2

Sitavig buccal tab limitacyclovir buccal tab 50 mg (Sitavig) — 2 Tablets Per 180 DAYS

Long-period capThis product uses a 180-day period rather than the common 30-day window

Brand designationListed as Brand (B)

inv-102: adalimumab auto-injector kit (Humira pen)

Humira kit and pen limitsadalimumab auto-injector kit (Humira pen) — 1 Kit Per 180 DAYS; Humira Pen presentations — 2 Pens Per 28 DAYS

Biosimilars similar capsMultiple adalimumab biosimilars/formulations are limited to 2 Pens or 2 Syringes Per 28 DAYS depending on presentation

Pharmacy noteEntries include Brand/Generic flags and require adherence to the 28-day pen/syringe limits

inv-103: adalimumab auto-injector kit 40 mg/0.4ml (Humira Pen) — 2

Humira pen 40 mg/0.4ml limitadalimumab auto-injector kit 40 mg/0.4ml (Humira Pen) — 2 Pens Per 28 DAYS

Brand flagEntry lists Brand (B) designation

Consistent across entriesOther Humira presentations reflect the same 2-pen per 28-day pattern where applicable

inv-104: adalimumab-aqvh soln auto-injector 40 mg/0.8ml (Yusimry) — 2 Pens

Yusimry pensadalimumab-aqvh soln auto-injector 40 mg/0.8ml (Yusimry) — 2 Pens Per 28 DAYS

Biosimilar patternOther biosimilar auto-injector presentations follow the 2 pens per 28 days convention

Brand/Generic codeListed with BG/B codes as shown in entries

inv-105: multiple adalimumab biosimilars and formulations — 2 Pens or 2 Syringes

Biosimilars general capmultiple adalimumab biosimilars and formulations — commonly limited to 2 Pens or 2 Syringes Per 28 DAYS depending on formulation

Includes pen and syringe presentationsLimits apply across both auto-injector pens and prefilled syringes per product lines

Provider actionDispensing claims should reflect the correct presentation (pen vs syringe) to apply the 2-per-28-day cap

inv-106: albuterol sulfate inhalers — 2 Inhalers

Albuterol inhalersalbuterol sulfate inhalers — 2 Inhalers Per 30 DAYS

Nebulization solution examplesalbuterol sulfate solution for nebulization — 120 Vials or 60 mLs or 125 Vials Per 30 DAYS depending on strength

Formulation-specific capsDifferent inhaler and nebulizer presentations have distinct per-30-day limits as listed

inv-107: albuterol sulfate solution for nebulization — multiple limits

Nebulization solution volumesalbuterol sulfate solution for nebulization — examples: 120 Vials Per 30 DAYS, or 60 mLs Per 30 DAYS, or 125 Vials Per 30 DAYS depending on strength

Strength dependenceThe specific vial count or mL cap depends on the solution concentration strength listed in the product line

Brand/generic codesEntries include BG/B/G designation as applicable

inv-108: adapalene pads 0.1% — 28 Pads

Adapalene pads countadapalene pads 0.1% — 28 Pads Per 28 DAYS

Topical presentationListed as a pad presentation with a per-28-day dispensing cap

Brand flagEntry shows Brand/Generic designation (B/BG) as in the list

inv-109: afatinib dimaleate (Gilotrif) 20/30/40 mg — 30 Tablets

Gilotrif tablet limitafatinib dimaleate (Gilotrif) 20/30/40 mg — 30 Tablets Per 30 DAYS

Multiple strengths same capMultiple afatinib strengths listed with the same 30-per-30-day cap

Brand designationEntries indicate Brand-only (B) status for Gilotrif strengths

inv-110: alirocumab auto-injector — 2 Pens

Praluent pen limitalirocumab auto-injector — 2 Pens Per 28 DAYS

Package mL equivalenceProduct notes 1 package = 2 mLs = 2 pens for certain strengths

Brand statusListed as Brand (B) in the product entry

inv-111: almotriptan tablets — 18 Tablets (cumulative)

Almotriptan tablet capalmotriptan tablets — 18 Tablets Per 30 DAYS (cumulative across oral triptans)

Cumulative rule referencedDocument explicitly notes the cumulative 18-tablet cap across all oral triptan agents

Brand/generic noteEntries list Brand/Generic flag as appropriate (G for almotriptan)

inv-112: amcinonide topical 0.1% — 100 Grams

Topical steroid cumulative limitamcinonide topical 0.1% — 100 Grams Per 30 DAYS (cumulative across agents)

Cumulative across formulationsThe 100 g per 30-day cap applies across topical corticosteroid agents listed as cumulative

Enforcement/claims notePharmacies should account for cumulative topical grams across agents when adjudicating claims

inv-113: amifampridine phosphate 10 mg (Firdapse) — 300 Tablets

Firdapse tablet limitamifampridine phosphate 10 mg (Firdapse) — 300 Tablets Per 30 DAYS

Brand statusListed as Brand (B)

Per-period enforcementLimit expressed per 30 days in the product entry

inv-114: amikacin liposome inhalation (Arikayce) — 28 Vials

Arikayce vial limitamikacin liposome inhalation (Arikayce) — 28 Vials Per 28 DAYS

Product-specific periodThis product uses a 28-day window for its vial limit

Brand designationListed as Brand (B)

inv-115: various amphetamine formulations — 30 or 60

Amphetamine family caps/tabletsvarious amphetamine formulations — typically 30 or 60 Tablets/Capsules Per 30 DAYS depending on formulation/dose

Formulation-specific capsExtended-release ODTs and other ER forms may have 30-per-30 or 60-per-30 limits per strength

Adherence notePharmacies must apply the correct per-formulation limit when dispensing stimulant products

Step Therapy

GLP-1 fill restriction

Certain high-cost and specialty injectable agents are subject to a fill restriction limiting the patient to one injectable GLP-1 agent (and one strength) per 28 days. Examples in the list include dulaglutide (Trulicity), exenatide (Bydureon), and other GLP-1 injectables. Pharmacies must enforce the "one injectable GLP-1 agent and one strength per 28 days" rule when adjudicating fills and ensure refill windows are honored. Requests for a different injectable GLP-1 agent or additional strength within the 28‑day window should be processed as a new request and may require prior authorization or be denied per plan rules.

Fill limit: one injectable GLP-1 agent and one strength per 28 days.
Examples: dulaglutide (Trulicity) — 4 Pens Per 28 DAYS with fill restriction; exenatide extended release (Bydureon) — 4 Pens Per 28 DAYS with fill restriction; exenatide pen formulations noted with 1 Pen Per 30/28 DAYS and subject to the same class restriction.
Pharmacies should verify prior fills of any injectable GLP-1 agent across all NDCs to enforce the limit.

Documentation Required

Member verification, long-interval limits, and documentation

Pharmacies and providers should verify member-specific plan limitations and state variations by consulting the member's plan documents or calling member services. When dispensing limits are long-interval (e.g., 1 Kit per 720 DAYS for some pump starter kits) or for devices/sensors with specific period caps, ensure claims quantities match the listed period to avoid denial. High-cost products assigned low Dispensing Limits may require additional documentation or prior authorization if the requested quantity exceeds the listed limit.

Long-interval device limits (example: 1 Kit per 720 DAYS for certain insulin pump starter kits) must be enforced.
Continuous glucose system receivers/transmitters/sensors have their own period limits (e.g., 1 Receiver per 365 DAYS; Transmitter per 90 DAYS; Sensors per 28–30 DAYS).
If additional documentation or PA is required to exceed a Dispensing Limit, the claim may be denied without it.