CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Performance Dispensing Limits (DL)

Defines quantity and time-period dispensing limits for specific prescription drugs and formulations for Blue Cross Blue Shield - Oklahoma members; affects prescribers, pharmacists, and members subject to the plan's pharmacy benefits.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPerformance Dispensing Limits (DL)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionIf a prescriber requests quantity beyond the listed dispensing limit, the excess quantity is not covered unless prior authorization or plan materials indicate otherwise.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipledrug entries with specific dispensing limits listed

30-/28-/180-daycommon time windows used for limits

60/2/1example quantity limits

100 mL / 300insulin & supplies examples

Coverage & Dispensing Limits

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Per-drug Dispensing Limits

Covered up to the specified dispensing limits for each listed drug.

example entries: 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; abacavir sulfate-lamivudine tab 600-300 mg (Epzicom) — Dispensing Limit = 30 Tablets Per 30 DAYSas listed per-drug

See product lines for many additional per-drug limits (examples in source chunks 1–3).

Product dispensing limits

Covered when dispensing does not exceed the listed product-specific limit.

Product-level dispensing limits: Each listed medication is covered up to the specified dispensing limit (for example: adalimumab formulations — Dispensing Limit = 2 Pens Per 28 DAYS for many auto-injector presentations).per product as listed

Many entries include a formulary availability flag (BG/B/G) alongside the limit.

Product dispensing limits (per product)

Coverage is subject to the following product-level dispensing limits and brand/generic designations:

Product-specific limit nodes: Each product entry lists: product name/formulation, Dispensing Limit = [quantity] Per [period]; and formulary status (BG/B/G). Example: amphetamine-dextroamphetamine cap ER 24hr 10 mg (Adderall XR) — Dispensing Limit = 30 Capsules Per 30 DAYS (status = BG).see individual product entries in chunks 36–55

The list contains many enforceable, product-level limits.

Product-specific dispensing limits (selected examples)

Each listed product is covered up to the specified dispensing limit for the given time window.

dexmethylphenidate XR: dexmethylphenidate HCl cap ER 24 hr (Focalin XR) — Dispensing Limit = 30 Capsules Per 30 DAYS (multiple ER strengths listed).30 Capsules Per 30 DAYS

Designation BG shown in product lines

dextroamphetamine formulations: dextroamphetamine sulfate (capsules, tablets, solution, patches) — Dispensing Limits vary by formulation (examples: oral solution 5 mg/5 mL = 1800 mLs Per 30 DAYS; certain ER capsules = 120 Capsules Per 30 DAYS; TD patches = 30 Patches Per 30 DAYS).see product-specific limits

Formulation-specific limits are enforceable per product entry

dulaglutide (Trulicity): dulaglutide auto-injector presentations — Dispensing Limit = 4 Pens Per 28 DAYS; fill limit of one injectable GLP-1 agent and one strength per 28 days (refill window applies).4 Pens Per 28 DAYS; class-level fill limit applies

Providers must honor fill-limit across GLP-1 class entries

triptans cumulative limit: Oral triptans and triptan combinations — Cumulative maximum = 18 Tablets Per 30 DAYS across all oral triptan agents and combinations.18 Tablets Per 30 DAYS across agents

Applies cumulatively across triptan products

diflorasone cumulative topical limit: Diflorasone diacetate topical formulations — Dispensing Limit = 100 Grams Per 30 DAYS (100/30 cumulative across agents).100 Grams Per 30 DAYS cumulative

Cumulative across diflorasone formulations

Per-product dispensing limits (applies to all listed drugs)

Covered up to the specified dispensing limit for each listed product.

Per-product dispensing rule: For each listed drug/formulation, coverage applies only to the stated quantity and time period (e.g., Trikafta tbpk formulation — 84 Tablets Per 28 DAYS; eliglustat (Cerdelga) — 60 Capsules Per 30 DAYS).per-item limits as listed

Use the exact product entry for adjudication

Dispensing limits by product

Covered when dispensing does not exceed the listed quantity limit and product matches listed brand/generic coverage indicator.

General rule: Dispensing must be at or below the product-specific limit and correspond to the listed formulary availability (B, G, or BG).per product limit

Limits and BG/B/G flags are shown on each product line

Examples from excerpt: Examples include: Vascepa (icosapent ethyl) — 120 Capsules Per 30 DAYS; Fanapt (iloperidone) tablets — 60 Tablets Per 30 DAYS or 1 Titration Pack Per 180 DAYS; imatinib (Gleevec) — 90 Tablets Per 30 DAYS; insulin products generally — 100 mLs Per 30 DAYS (cumulative across injectable formulations); insulin infusion pump kits — 1 Kit Per 720 DAYS; Omnipod reservoirs — 30 Pods Per 30 DAYS.see example entries

Representative product-level limits from insulin, psychiatric, and specialty agents

Quantity limits

Covered when dispensing does not exceed the stated per-30-day limits.

Insulin volume limits: Most insulin solutions and pen injectors (e.g., lispro formulations, Humalog, Admelog, Lyumjev) — Dispensing Limit = 100 mLs Per 30 DAYS; quantity limits may be cumulative across injectable formulations.100 mLs Per 30 DAYS

See insulin product lines for cumulative rules across pens/vials/cartridges

Supply caps (syringes/needles): Insulin pen needles and insulin syringes — Dispensing Limit = 300 units Per 30 DAYS (quantity cumulative across all listed pen needles/syringes).300 Per 30 DAYS cumulative

Applies across all listed pen needle/syringe SKUs

Afrezza cartridges: Afrezza inhalation cartridges — Coverage limited to SKU-specific cartridge counts (examples include 1260, 1080, 1800, 900, 2520 cartridges Per 30 DAYS depending on cartridge size).SKU-specific cartridge counts Per 30 DAYS

Refer to cartridge-size-specific lines for exact limits

Dispensing limits (general)

Products listed are subject to the specified dispensing quantity limits (QL) and any quantity requests beyond these limits require appropriate justification or prior authorization.

Per-product quantity limits: Each product entry includes an exact dispensing limit and time period (e.g., '300 Syringes Per 30 DAYS'). Where the entry notes 'cumulative', the limit applies across formulations or strengths. Exceeding the listed limit may require documentation or prior authorization.per product as listed

Providers should submit supporting documentation for quantities beyond the listed limit.

Selected product examples

Examples of product-specific limits included in this section:

Insulin syringes example: Insulin syringes (multiple brands/sizes) — Dispensing Limit = 300 Syringes Per 30 DAYS; quantity cumulative across all insulin syringe SKUs.300 Syringes Per 30 DAYS cumulative

Applies across listed insulin syringe SKUs

Interferon beta products example: Interferon beta products: Betaseron — 14 Vials Per 28 DAYS; Extavia — 15 Vials Per 30 DAYS; Rebif kits — 1 Kit Per 180 DAYS; Avonex kits — 1 Kit Per 28 DAYS; Rebif syringes — 12 Syringes Per 28 DAYS (cumulative across strengths).varies by product

Per-product carton/kit counts and cumulative rules specified in source

Biologics example: Examples include ixekizumab (Taltz) — 1 Syringe Per 28 DAYS; lebrikizumab (Ebglyss) — 1 Syringe/Pen Per 28 DAYS; Takhzyro — 2 Vials/Syringes Per 28 DAYS.per product as listed

Limits shown per specific biologic presentations

Dispensing Limits (general)

Covered when dispensed within the specified quantity limit and time period for each product.

Per-product dispensing limits: Each listed product is covered up to the exact dispensing limit specified (quantity and time period). Some products include notes that the quantity limit is cumulative across formulations; those cumulative limits apply to the combined total dispensed.see per-product entries

Limits and BG/B/G flags provided per line

Product dispensing limits

Products and their dispensing limits (partial list):

Example product entries: Examples include: lisdexamfetamine (Vyvanse) — 30 Capsules Per 30 DAYS; lisinopril oral solution (Qbrelis) — 2400 mLs Per 30 DAYS; lorazepam tablets — 150 Tablets Per 30 DAYS; loteprednol (Eysuvis) — 16.6 mLs Per 90 DAYS; lusutrombopag (Mulpleta) — 7 Tablets Per 7 DAYS; mepolizumab (Nucala) — 1–3 Pens/Syringes Per 28 DAYS depending on presentation; multiple methylphenidate formulations with varying per-30-day limits.varies by product

This is a partial extract; use the exact product line for adjudication.

Some member plans may exclude coverage for specific agents or entire drug categories; the policy text cites erectile dysfunction agents as an example of a category that some plans exclude. In addition, certain products may be restricted from mail-service distribution and coverage of specialty or select non‑specialty medications may be limited to a 30‑day supply based on the member's benefit plan. Providers and members should verify plan‑specific limitations or exclusions by reviewing plan materials or calling the number on the member ID card.

The source does not list standalone clinical exclusions beyond the dosing caps; rather, it indicates that coverage applies only up to the stated dispensing quantities. For example, oral triptans are subject to a cumulative cap of 18 tablets per 30 days, and entries otherwise function as per‑product quantity caps rather than therapeutic exclusions.

The document segment focuses on outpatient dispensing limits and does not set out special coverage exceptions for inpatient administration or other sites of care. Entries specify allowable outpatient quantities and time windows (for example, azithromycin entries reference a cumulative cap per 180 days and topical diflorasone entries reference cumulative gram limits), but no inpatient administration carve‑outs are described.

There are no explicit clinical exclusion criteria in these excerpts; the policy implements operational quantity limits (e.g., cumulative topical gram caps or triptan tablet caps) rather than denying coverage on clinical grounds. Limits are administrative controls applied to dispensing.

Any request for quantities that exceed the per‑product dispensing limit shown in the list is outside the allowance of the dispensing‑limits catalog and would need additional review; for example, triptan and other product lines explicitly state per‑period maximums and do not authorize amounts above those maxima without prior approval.

When a dispensed quantity exceeds the stated product limit the policy indicates that coverage only applies up to the limit; amounts in excess of the dispensing limit are not covered by the plan and the member may be responsible for the full cost unless plan materials specify otherwise.

Product Lists & Coding Details

Per-Product Quantity Limits (A–M)

abacavir sulfate soln 20 mg/ml (Ziagen)

Productabacavir sulfate soln 20 mg/ml (Ziagen)

Dispensing Limit960 mLs Per 30 DAYS

Formulary statusBG (brand and generic) indicated in product line

abacavir sulfate tab 300 mg (Ziagen)

Productabacavir sulfate tab 300 mg (Ziagen)

Dispensing Limit60 Tablets Per 30 DAYS

Formulary statusBG (brand and generic) indicated in product line

abaloparatide subcutaneous soln pen-injector 3120 mcg/1.56ml (Tymlos)

Productabaloparatide subcutaneous soln pen-injector 3120 mcg/1.56ml (Tymlos)

Dispensing Limit1.56 mLs Per 30 DAYS (1 injection)

Formulary statusB (brand) indicated

abatacept subcutaneous soln (Orencia)

Productabatacept subcutaneous soln (Orencia)

Dispensing Limit4 Syringes Per 28 DAYS

Formulary statusB (brand) indicated

abemaciclib tab (Verzenio)

Productabemaciclib tab (Verzenio)

Dispensing Limit60 Tablets Per 30 DAYS

Formulary statusB (brand) indicated

acloramidis/acaromidis (Attruby) pack example

Product exampleacoramidis/acaromidis (Attruby) pack example

Dispensing Limit112 Tablets Per 28 DAYS

Formulary statusB (brand) indicated

adalimumab auto-injector kit (Humira pen)

Productadalimumab auto-injector kit (Humira pen)

Dispensing Limit1 Kit Per 180 DAYS or 2 Pens Per 28 DAYS depending on presentation

Formulary statusB / BG as noted per product line

adalimumab-aqvh soln auto-injector 40 mg/0.8ml (Yusimry)

Productadalimumab-aqvh soln auto-injector 40 mg/0.8ml (Yusimry)

Dispensing Limit2 Pens Per 28 DAYS

Formulary statusB indicated in product line

multiple adalimumab formulations/biosimilars (various strengths and presentations)

Product groupmultiple adalimumab formulations/biosimilars (various strengths and presentations)

Dispensing LimitTypically 2 pens or 2 syringes per 28 DAYS as listed per SKU

NoteLimits vary by presentation and are enforced per listed product line

albuterol sulfate inhalers (HFA/Respiclick/Digihaler)

Productalbuterol sulfate inhalers (HFA/Respiclick/Digihaler)

Dispensing Limit2 Inhalers Per 30 DAYS

Formulary statusBG (brand & generic) indicated in lines

albuterol sulfate solution nebu

Productalbuterol sulfate solution nebu

Dispensing Limit120 Vials Per 30 DAYS (other nebu volumes also listed)

Formulary statusBG indicated

almotriptan malate tablets (6.25 mg & 12.5 mg)

Productalmotriptan malate tablets (6.25 mg & 12.5 mg)

Dispensing Limit18 Tablets Per 30 DAYS (cumulative across oral triptans)

Formulary statusG indicated for almotriptan entries

amcinonide topical formulations

Productamcinonide topical formulations (cream, lotion, ointment)

Dispensing Limit100 Grams Per 30 DAYS; 100/30 cumulative across agents

Formulary statusB indicated for amcinonide entries

alpelisib (Piqray) tab pack 250 mg daily dose

Productalpelisib (Piqray) tab pack 250 mg daily dose

Dispensing Limit56 Tablets Per 28 DAYS

Formulary statusB indicated

Adzenys XR-ODT 9.4 mg

ProductAdzenys XR-ODT 9.4 mg

Dispensing Limit30 Tablets Per 30 DAYS

Formulary statusB indicated

Kineret (anakinra) 100 mg/0.67 mL prefilled syringe

ProductKineret (anakinra) 100 mg/0.67 mL prefilled syringe

Dispensing Limit28 Syringes Per 28 DAYS

Formulary statusB indicated

Azithromycin (250 mg, 500 mg, 600 mg formulations)

ProductAzithromycin (250 mg, 500 mg, 600 mg formulations)

Dispensing Limit60 Tablets Per 180 DAYS; quantity limit cumulative across strengths

Formulary statusBG/G as indicated per line

Per-Product Quantity Limits (N–Z)

Provider Requirements & Adjudication Guidance

Billing Rule

Dispensing limits govern claim adjudication

Dispensing limits listed in this policy govern claim adjudication. The policy defines product‑specific maximum quantities (quantity per days) and class‑level fill limits that are enforced at the point of sale; claims will be paid only to the listed dispensing limit unless an approved override exists.

Dispensing limits are expressed as quantity per time period (e.g., 30 tablets per 30 days, 1 kit per 180 days).
Class-level fill limits apply where noted (example: injectable GLP‑1 agents — fill limit of one injectable GLP‑1 agent and one strength per 28 days).
Some dispensing limits are cumulative across formulations or agents within a class (example: insulin/glargine cumulative limits; triptan cumulative maximums).

Prior Authorization

Prior authorization likely for quantities beyond listed limits

When a dispensing request exceeds the listed dispensing limit for a product, prior authorization or other utilization review is likely required — otherwise the claim may be denied or the member may be responsible for the amount beyond the limit. The policy does not describe a separate prior authorization form or workflow; it specifies that over‑limit dispensing will be subject to plan processes (prior authorization, override review, or denial).

Coverage applies only up to the listed dispensing limit; any quantity beyond the limit may be the member's financial responsibility.
Exceeding a listed dispensing limit can trigger a benefit edit denial at adjudication unless an approved prior authorization or override is obtained.
The document references prior authorization as the mechanism for permitting quantities above limits, but does not provide the PA submission details in this section.

Documentation Required

Special clinical criteria referenced

Certain products reference special clinical criteria or a "Special Clinical Criteria Table" to calculate quantity limits (for example, weight‑based calculations for C1 esterase inhibitors). Higher quantities or alternate calculations may require submission of supporting clinical documentation for review.

Some biologics and specialty injectables have *QL calculation* notes (e.g., CDC 90th percentile weight used for vial calculations); see the Special Clinical Criteria Table when indicated.
Supporting documentation (weight, dosing rationale, attack frequency, cumulative dosing) may be required for quantity calculations and overrides.
Products with an asterisk or 'See Special' note in the list should be referred to the clinical criteria table for adjudication requirements.

Prior Authorization

Dispensing limits enforceable via prior authorization

Dispensing limits are enforceable via prior authorization and benefit edits. Where a product lists a maximum allowable dispensing quantity per time period (including starter packs and device kits), dispensing beyond that maximum will generally require an approved prior authorization or will be denied at claim adjudication.

Starter packs and induction kits often have long period limits (example: 1 pack per 180 days for certain starter packs).
High‑cost specialty injectables and devices (e.g., biologics, infusion pumps) have defined limits that typically require PA for additional supply.
Insulin pump devices and starter kits have multi‑year limits (example: 1 kit per 720 days) and will require clinical review for replacement outside the window.

Prior Authorization

Prior authorization (not listed)

This section does not list detailed prior authorization submission steps or forms; it provides quantity limits and notes when PA is the expected mechanism for exceptions. Providers should follow plan‑specific prior authorization processes (as provided in separate PA guidance) for override requests.

Prior authorization is referenced as the expected route for approvals above the listed limits but the PA process itself is not described here.
Providers should consult plan materials or contact the number on the member ID card to determine the correct PA pathway.
When seeking an override, include the clinical rationale, dosing calculations, and any required weight or treatment history documentation.

Prior Authorization

Prior authorization for over‑limit dispensing

Dispensing beyond the stated quantity limits will generally require prior authorization or will be subject to denial. Claims exceeding per‑period quantity limits are at risk for benefit edit denial unless supporting documentation justifies an exception and a PA/override is approved.

Claims paid only to the policy limit — amounts above the limit may be denied or billed to the member.
Exceeding listed dispensing limits may trigger automated benefit edits or manual review.
Plan processes may allow overrides when clinical documentation supports the medical necessity of the higher quantity.

Prior Authorization

Prior authorization for quantities above dispensing limit

When a dispensed quantity exceeds the listed limit for a product, prior authorization may be required and the claim may be denied if an approved override is not in place. Providers should not assume coverage for quantities above the published dispensing limit without prior approval.

If a prescriber requests quantity beyond the listed limit, the excess quantity is not covered without PA.
Providers should obtain PA before dispensing amounts above the limit to avoid member liability.
Document the medical necessity and reason for the higher quantity when submitting an override request.

Billing Rule

Class-level fill limits

Class-level fill limits and cumulative quantity rules are included and must be followed during adjudication. Examples include cumulative triptan limits across agents and fill limits that apply across injectable formulations of the same drug class.

Oral triptans and triptan combination products: cumulative maximum of 18 tablets per 30 days across all agents.
Injectable GLP‑1 agents: fill limit of one injectable GLP‑1 agent and one strength per 28 days; refill window applies.
Quantity limits may be cumulative across formulations (e.g., insulin glargine and other injectable insulin formulations).

Prior Authorization

Prior authorization for specialty injectables

Certain specialty injectables and biologics have specified dispensing limits and will commonly require prior authorization for quantities exceeding those limits. Providers should prepare to supply clinical documentation for PA or appeals.

Examples: C1 esterase inhibitors, certain monoclonal antibodies and other high‑cost biologics have explicit vial/kit limits per 28–30 days.
Some specialty agents include weight‑based QL calculations which require supporting weight and dosing information.
Starter packs and induction kits for biologics often have separate longer‑term limits (e.g., 1 kit per 180 days).

Prior Authorization

Prior authorization for pump kits

High‑cost devices (insulin infusion pumps and starter kits) and their consumables have long dispensing windows and strict limits (for example, pump devices and starter kits limited to 1 kit per 720 days). Prior authorization or clinical review is likely required for replacement or additional kits outside the stated window.

Insulin infusion pump devices and starter kits: example limits of 1 kit per 720 days.
Pump supplies and reservoirs have monthly kit/pod limits (example: 30 pods per 30 days; up to 20 kits per 30 days for some devices).
Replacement pumps, starter kits, or additional device supplies outside the window will require clinical justification and PA.

Documentation Required

Required claim documentation

Adjudicators and providers must match the claim item to the listed product/kit name and the policy quantity unit when validating limits. Required claim documentation may include dosing calculations, cumulative quantity history, weight data for weight‑based QLs, and identification of starter kit versus maintenance supply.

Match the claim line item to the exact kit or product name listed in the dispensing limits table (e.g., 'Eliquis Starter Pack', specific pump kit names).
Provide cumulative quantity documentation when limits are cumulative across agents or formations.
For weight‑based QLs, include patient weight and dosing rationale in the claim or PA supporting documentation.

Note

Verification required

Verification is required: members or providers should verify plan‑specific limitations, exclusions, and PA requirements by reviewing plan materials or calling the member ID card phone number. The dispensing limits list is subject to change and may not apply uniformly across all members or states.

Check the member's benefit plan or contact the number on the back of the member ID card to confirm limits and PA processes.
Some limits may vary by state regulation or specific benefit plan design.
This list is subject to change; always verify current plan materials prior to dispensing beyond listed limits.

Background & Definitions

Dispensing limits are described as an administrative tool to promote medication use consistent with FDA dosing and intended use. The policy notes that limits may vary by drug formulation, brand/generic status, member plan, and state regulations, and that coverage limits are placed on medications in certain categories to control quantity dispensed.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPerformance Dispensing Limits (DL)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionIf a prescriber requests quantity beyond the listed dispensing limit, the excess quantity is not covered unless prior authorization or plan materials indicate otherwise.

SourceLink

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