Dispensing Limits Performance Ok

Coverage Summary & Scope

This policy lists product-level dispensing (quantity) limits for many medications by formulation and time window (e.g., per 28/30/84/90/180/365 days). It identifies the member cost responsibility when prescribed quantities exceed the listed dispensing limit (member may obtain the medication but will pay the full cost beyond coverage). Brand/generic substitution status is indicated per SKU (codes BG/B/G) and limits may vary by plan or state.

Some limits are cumulative across formulations or classes (for example, topical corticosteroids with gram-based cumulative caps and oral triptans with a cumulative tablet limit). The policy also highlights special handling for GLP-1 agents (injectable and oral) that limit fills to one injectable or one oral GLP-1 agent and one strength per 28 days, and notes when products are restricted from mail service or limited as specialty items.

Key thresholds and cross-product rules

Oral triptans cumulative limitMaximum of 18 tablets per 30 days across all oral triptan agents

Amcinonide/topical corticosteroids cumulative limit100 grams per 30 days cumulative across listed topical steroid agents

Insulin syringe monthly limit300 syringes per 30 days (quantity limit cumulative across all insulin syringe SKUs)

GLP-1 injectable fill limitOne injectable GLP‑1 agent and one strength may be filled per 28 days (refill window applies)

GLP-1 oral fill limitOne oral GLP‑1 agent and one strength may be filled per 28 days (refill window applies)

Annovera (segesterone/ethinyl ring)1 ring per 365 days (max 365 days supplied per prescription)

General Policy Rules & Applicability

General Policy Rules

Covered when ALL of the following general policy rules are met:

ALL of the following

Drug dispensing limits help encourage medication use as intended by the FDA. Coverage limits are placed on medications in certain drug categories.
Limits may include: - Quantity of covered medication per prescription - Quantity of covered medication in a given time period
If your doctor prescribes a greater quantity of medication than what the dispensing limit allows, you can still get the medication. However, you will be responsible for the full cost of the prescription beyond what your coverage allows.
The following brand drugs, and their generic equivalents, if available, have dispensing limits. Some of these dispensing limits may not apply to all members or may vary based on state regulations.

Drug-specific Dispensing Limits (detailed list)

The following code groups present product-level dispensing limits and brand/generic flags extracted across the document parts. Groups are organized by the data partitions provided in the brief (Part 1, product-level, mixed parts). The entries below list the product name as the code and a short description showing the dispensing limit and the brand/generic flag.

Drug dispensing limits and brand/generic flags (listed drugs in this part)NDC|mixed

amphetamine tab extended release 5 mg (Dyanavel Xr)	Dispensing Limit = per plan; [B]
amphetamine tab extended release disintegrating 12.5 mg (Adzenys Xr-Odt)	Dispensing Limit = per plan; [B]
amphetamine tab extended release disintegrating 12.5 mg (Amphetamine Er Odt)	Dispensing Limit = per plan; [B]
amphetamine tab extended release disintegrating 15.7 mg (Adzenys Xr-Odt)	Dispensing Limit = per plan; [B]
amphetamine tab extended release disintegrating 15.7 mg (Amphetamine Er Odt)	Dispensing Limit = per plan; [B]
amphetamine tab extended release disintegrating 18.8 mg (Adzenys Xr-Odt)	Dispensing Limit = per plan; [B]
amphetamine tab extended release disintegrating 18.8 mg (Amphetamine Er Odt)	Dispensing Limit = per plan; [B]
amphetamine tab extended release disintegrating 3.1 mg (Adzenys Xr-Odt)	Dispensing Limit = per plan; [B]
amphetamine tab extended release disintegrating 3.1 mg (Amphetamine Er Odt)	Dispensing Limit = per plan; [B]
amphetamine tab extended release disintegrating 6.3 mg (Adzenys Xr-Odt)	Dispensing Limit = per plan; [B]

1–10 of 30

1/3

Dispensing limits and brand/generic status (product-level)mixed

anakinra subcutaneous 100 mg/0.67ml (Kineret)	Dispensing Limit = per plan; [B]
antihemophil factor (Xyntha; Xyntha solofuse)	Dispensing Limit = per plan; [B]
antihemophil factor (Nuwiq)	Dispensing Limit = per plan; [B]
antihemophilic fact rcmb (Novoeight)	Dispensing Limit = per plan; [B]
antihemophilic factor (human) (Hemofil M; Koate; Koate-dvi)	Dispensing Limit = per plan; [BG]
apalutamide tab 240 mg (Erleada)	Dispensing Limit = per plan; [B]
apalutamide tab 60 mg (Erleada)	Dispensing Limit = per plan; [B]
apixaban cap sprinkle 0.15 mg (Eliquis)	Dispensing Limit = per plan; [B]
apixaban tab 2.5 mg (Eliquis)	Dispensing Limit = per plan; [B]
apixaban tab 5 mg (Eliquis)	Dispensing Limit = per plan; [B]

1–10 of 13

1/2

Drug dispensing limits and brand/generic statusNDC|mixed

apremilast start pack (multiple strengths)	Dispensing Limit = per plan; [B]
apremilast starter therapy pack (10/20/30 mg)	Dispensing Limit = per plan; [B]
aprepitant therapy pack 80 & 125 mg (Emend Tripack)	Dispensing Limit = per plan; [B]
arimoclomol citrate cap (Miplyffa) 124/93/62 mg	Dispensing Limit = per plan; [B]
aripiprazole tab 10 mg with sensor (Mycite Maintenance Kit)	Dispensing Limit = per plan; [B]
aripiprazole tab 10 mg with sensor starter kit (Abilify Mycite Starter Kit)	Dispensing Limit = per plan; [B]
aripiprazole tab 15 mg (Abilify)	Dispensing Limit = per plan; [B]
aripiprazole tab 15 mg with sensor kits	Dispensing Limit = per plan; [B]
aripiprazole tab 2 mg (Abilify)	Dispensing Limit = per plan; [B]
aripiprazole tab 2 mg with sensor kits	Dispensing Limit = per plan; [B]

1–10 of 16

1/2

Drug-level dispensing limits and brand/generic flagsNDC|mixed

asenapine maleate sl tab 10/5/2.5 mg (Saphris)	Dispensing Limit = per plan; [B]
asenapine td patch 24 hr (Secuado) 3.8/5.7/7.6 mg/24hr	Dispensing Limit = per plan; [B]
aspirin-omeprazole tab DR 325-40 mg & 81-40 mg (Yosprala)	Dispensing Limit = per plan; [B]
atazanavir sulfate cap 150 mg	Dispensing Limit = per plan; [B]
atazanavir sulfate cap 200 mg (Reyataz)	Dispensing Limit = per plan; [B]
atazanavir sulfate cap 300 mg (Reyataz)	Dispensing Limit = per plan; [B]
atazanavir sulfate oral powder packet 50 mg (Reyataz)	Dispensing Limit = per plan; [B]
atazanavir-cobicistat tab 300-150 mg (Evotaz)	Dispensing Limit = per plan; [B]
atogepant tab 10/30/60 mg (Qulipta)	Dispensing Limit = per plan; [B]
atomoxetine hcl cap (Strattera) 10/18/25/40/60/80/100 mg	Dispensing Limit = per plan; [B]

1–10 of 11

1/2

Drug dispensing limits entriesmixed

atrasentan hcl tab 0.75 mg (Vanrafia)	Dispensing Limit = per plan; [B]
avacopan cap 10 mg (Tavneos)	Dispensing Limit = per plan; [B]
avanafil tab 50/100/200 mg (Stendra)	Dispensing Limit = per plan; [B]
avapritinib tab 25/50/100/200/300 mg (Ayvakit)	Dispensing Limit = per plan; [B]
avatrombopag maleate cap sprinkle 10 mg (Doptelet Sprinkle)	Dispensing Limit = per plan; [B]
avatrombopag maleate tab 20 mg (Doptelet)	Dispensing Limit = per plan; [B]
avutometinib cap 0.8 mg & defactinib tab 200 mg co-pack	Dispensing Limit = per plan; [B]
azacitidine tab 200/300 mg (Onureg)	Dispensing Limit = per plan; [B]
azilsartan medoxomil tab 40/80 mg (Edarbi)	Dispensing Limit = per plan; [BG]
azilsartan-chlorthalidone tab 40-12.5 mg & 40-25 mg (Edarbyclor)	Dispensing Limit = per plan; [BG]

Note: The brief includes only a partial list. The full policy contains many more SKUs. Enforce cumulative rules across entries where applicable (for example: topical steroid cumulative grams, triptan cumulative tablet limits, and GLP-1 one-agent rule) when applying dispensing limits to claims and prior authorization decisions.

Provider & Pharmacy Actions

Documentation Required

Inform member cost responsibility

If prescribed quantity exceeds the dispensing limit, provider/pharmacy must inform member that they can obtain the medication but will be responsible for cost beyond coverage.

Billing Rule

Insulin syringe monthly limit

Insulin syringe dispensing limit is cumulative across all insulin syringe SKUs; pharmacies must not dispense more than the listed limit within the timeframe.

Insulin syringe limit: 300 Syringes Per 30 DAYS (cumulative across all insulin syringes)

Definitions & Background

Dispensing limits are applied to encourage FDA-intended use and specify the maximum quantity covered per prescription or within a time period. Limits may be cumulative across classes (examples include topical steroid grams and oral triptan tablet caps), and each SKU includes a substitution status code (BG = generic and brand, B = brand only, G = generic only). Limits can vary by plan or state, and the policy includes notes on mail-service availability and specialty/mail restrictions.

Term	Definition
Dispensing Limit
The maximum quantity of a medication covered by the plan per specified time period (e.g., per 28 or 30 days, per 180 days).
BG/B/G
BG = Generic and Brand; B = Brand Only; G = Generic only (indicates availability/coverage status in list).
BG
Generic and Brand
B
Brand Only
G
Generic Only
QL
Quantity Limit / cumulative across strengths (applies where noted; e.g., oral triptans maximum 18 tablets per 30 days across agents; some topical agents cumulative 100 g/30 days).

Code Groups & Flags

Formulation/Brand availability indicator used in listmixed

BG	Generic and Brand
B	Brand Only
G	Generic Only

Formulation/Brand availability indicator - notemixed

NOTE	These indicators (BG/B/G) are used throughout the product lists to denote substitution/coverage status.

Substitution status codesmixed

BG	Generic and Brand
B	Brand Only
G	Generic only

Substitution status codes - source notemixed

NOTE	Source defines BG = Generic and Brand; B = Brand Only; G = Generic Only.

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