CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Dispensing Limits Performance Select Ok

Defines quantity/dispensing limits applied to specific branded drugs and their generics for Blue Cross Blue Shield - Oklahoma (Performance Select). Lists per-drug maximum quantities per time period and whether limit applies to brand/generic/both. Applies to pharmacy dispensing and member cost responsibility for quantities above limits.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyDispensing Limits Performance Select Ok

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders or members should verify plan-specific dispensing limits and exclusions via plan materials or by calling the number on the member's ID card.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — has_material_change = false.

multipleCumulative-limit rules present

30/28/180Typical time windows referenced

1GLP-1 injectable fill limit rule

1Cumulative triptan rule

0Material change

Policy summary

This policy is the Performance Select (Blue Cross Blue Shield - Oklahoma) Dispensing Limits policy that defines pharmacy quantity/dispensing limits by product, strength, form and brand/generic designation (B/BG/G). It applies to covered pharmacy benefits under the Performance Select program and to pharmacies, prescribers, and members; each listed product has a maximum quantity allowed to be dispensed within the specified timeframe and some limits are cumulative across formulations or drug classes. If a prescriber writes for more than the stated dispensing limit, members may still obtain the medication but are responsible for the full cost beyond coverage. (See member verification instructions in plan materials or via the number on the back of the member ID.)

General dispensing limit rules

General Dispensing Limit Policy

The following general rules apply to dispensing limits. Limits may include quantity per prescription and quantity within a time period. If a prescriber provides a quantity greater than the dispensing limit, the member may obtain additional product but will be responsible for costs beyond plan limits. Some limits may be cumulative across products in a class, vary by state or plan, or not apply to all members; verify member benefits for exceptions.

ALL of the following

Dispensing limits are applied as specified per product entry below.
Limits may be expressed as units (tablets, mL, inhalers, kits, syringes, vials) per specified day range (eg, Per 30 DAYS, Per 28 DAYS, Per 180 DAYS).
Brand/generic designation follows each product entry where provided: BG = Brand and Generic, B = Brand Only, G = Generic Only.
Some dispensing limits are cumulative across multiple medications within a drug class; per-leaf notes indicate when QL cumulative applies.

Dispensing limits - product list

The following product-level dispensing limit entries list individual products and their per-period limits. Brand/generic designations are shown where available. Preserve any per-leaf notes about cumulative limits.

abacavir sulfate soln 20 mg/ml (Ziagen) — Dispensing Limit = 960 mLs Per 30 DAYS. Designation: BG.

abacavir sulfate tab 300 mg (Ziagen) — Dispensing Limit = 60 Tablets Per 30 DAYS. Designation: BG.

abacavir sulfate-lamivudine tab 600-300 mg (Epzicom) — Dispensing Limit = 30 Tablets Per 30 DAYS. Designation: BG.

abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg (Trizivir) — Dispensing Limit = 60 Tablets Per 30 DAYS. Designation: B.

abacavir-dolutegravir-lamivudine tab 600-50-300 mg (Triumeq) — Dispensing Limit = 30 Tablets Per 30 DAYS. Designation: B.

Quantity limits / Dispensing limits

The following grouped quantity/dispensing limits are presented by product groups or therapies. Nested entries preserve per-leaf operational notes such as cumulative QL statements and unit conversions.

ALL of the following

Insulins & Syringes
- Insulin syringes — Dispensing limits may be expressed as Syringes Per 30 DAYS; QL cumulative across syringe types may apply. (Specific limits depend on plan documentation and are indicated per product where listed).
Injectable biologics
- Abaloparatide (Tymlos) pen-injector — Dispensing Limit = 1.56 mLs Per 30 DAYS; 1.56 mLs = 1 injection. Designation: B.
- Abatacept (Orencia) prefilled syringes/auto-injectors — Dispensing Limit = 4 Syringes Per 28 DAYS. Designation: B.

Drug list and code groups (NDC / product descriptions)

Edoxaban (Savaysa)mixedCovered

edoxaban tosylate tab 15 mg	Savaysa 15 mg tablet
edoxaban tosylate tab 30 mg	Savaysa 30 mg tablet
edoxaban tosylate tab 60 mg	Savaysa 60 mg tablet

Efavirenz and Efavirenz CombinationsmixedCovered

efavirenz cap 200 mg	Efavirenz 200 mg capsule
efavirenz cap 50 mg	Efavirenz 50 mg capsule
efavirenz tab 600 mg	Efavirenz 600 mg tablet
efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg	Efavirenz/Emtricitabine/Tenofovir DF 600-200-300 mg tablet
efavirenz-lamivudine-tenofovir df tab 400-300-300 mg	Efavirenz/Lamivudine/Tenofovir DF 400-300-300 mg tablet
efavirenz-lamivudine-tenofovir df tab 400-300-300 mg (Symfi Lo)	Symfi Lo 400-300-300 mg tablet
efavirenz-lamivudine-tenofovir df tab 600-300-300 mg (Symfi)	Symfi 600-300-300 mg tablet

EfgartigimodmixedCovered

efgartigimod pref syringe 1000-10000 mg-unit/5 ml

Vyvgart Hytrulo prefilled syringe 1000-10000 mg per 5 mL

Elacestrant (Orserdu)mixedCovered

elacestrant hydrochloride tab 345 mg	Orserdu 345 mg tablet
elacestrant hydrochloride tab 86 mg	Orserdu 86 mg tablet

Elagolix (Orilissa) and OriahnnmixedCovered

elagolix sodium tab 150 mg	Orilissa 150 mg tablet
elagolix sodium tab 200 mg	Orilissa 200 mg tablet
elagolix-estradiol-noreth pack	Oriahnn pack (elagolix with estradiol and norethindrone)

Eletriptan (Relpax)mixedCovered

eletriptan hydrobromide tab 20 mg	Relpax 20 mg tablet
eletriptan hydrobromide tab 40 mg	Relpax 40 mg tablet

Elexacaftor-Tezacaftor-Ivacaftor (Trikafta)mixedCovered

elexacaftor-tezacaftor-ivacaftor + ivacaftor 150 mg	Trikafta 150 mg formulation (combination plus ivacaftor)
elexacaftor-tezacaftor-ivacaftor + ivacaftor 75 mg packets	Trikafta 75 mg packets (combination plus ivacaftor)
elexacaftor-tezacaftor-ivacaftor 50-25-37.5 mg + ivacaftor 75 mg	Trikafta 50-25-37.5 mg tablets with ivacaftor 75 mg
elexacaftor-tezacaftor-ivacaftor 80-40-60 mg + ivacaftor 59.5 mg packets	Trikafta 80-40-60 mg tablets with ivacaftor 59.5 mg packets

Eltrombopag (Alvaiz / Promacta)mixedCovered

eltrombopag choline tab 9 mg	Alvaiz 9 mg tablet (eltrombopag choline)
eltrombopag choline tab 18 mg	Alvaiz 18 mg tablet (eltrombopag choline)
eltrombopag choline tab 36 mg	Alvaiz 36 mg tablet (eltrombopag choline)
eltrombopag choline tab 54 mg	Alvaiz 54 mg tablet (eltrombopag choline)
eltrombopag olamine powder pack 12.5 mg	Promacta 12.5 mg powder pack (eltrombopag olamine)
eltrombopag olamine powder pack 25 mg	Promacta 25 mg powder pack (eltrombopag olamine)
eltrombopag olamine tab 12.5 mg	Promacta 12.5 mg tablet
eltrombopag olamine tab 25 mg	Promacta 25 mg tablet
eltrombopag olamine tab 50 mg	Promacta 50 mg tablet
eltrombopag olamine tab 75 mg	Promacta 75 mg tablet

Eluxadoline (Viberzi)mixedCovered

eluxadoline tab 75 mg	Viberzi 75 mg tablet
eluxadoline tab 100 mg	Viberzi 100 mg tablet

Elvitegravir Combinations (Genvoya / Stribild)mixedCovered

elvitegravir-cobicistat-emtricitabine-tenofovir af tab 150-150-200-10 mg	Genvoya 150-150-200-10 mg tablet
elvitegravir-cobicistat-emtricitabine-tenofovir df tab 150-150-200-300 mg	Stribild 150-150-200-300 mg tablet

Empagliflozin and Combinations (Jardiance, Glyxambi, Trijardy, Synjardy)mixedCovered

empagliflozin tab 10 mg	Jardiance 10 mg tablet
empagliflozin tab 25 mg	Jardiance 25 mg tablet
empagliflozin-linagliptin tab 10-5 mg	Glyxambi 10-5 mg tablet
empagliflozin-linagliptin tab 25-5 mg	Glyxambi 25-5 mg tablet
empagliflozin-linagliptin-metformin ER 24hr 5-2.5-1000 mg	Trijardy XR 5-2.5-1000 mg ER
empagliflozin-linagliptin-metformin ER 24hr 10-5-1000 mg	Trijardy XR 10-5-1000 mg ER
empagliflozin-linagliptin-metformin ER 24hr 12.5-2.5-1000 mg	Trijardy XR 12.5-2.5-1000 mg ER
empagliflozin-linagliptin-metformin ER 24hr 25-5-1000 mg	Trijardy XR 25-5-1000 mg ER
empagliflozin-metformin HCl tab 5-500 mg	Synjardy 5-500 mg tablet
empagliflozin-metformin HCl tab 5-1000 mg	Synjardy 5-1000 mg tablet

1–10 of 16

1/2

Emtricitabine / Rilpivirine / Tenofovir and Descovy/TruvadamixedCovered

emtricitabine-rilpivirine-tenofovir AF tab 200-25-25 mg	Odefsey 200-25-25 mg tablet
emtricitabine-rilpivirine-tenofovir DF tab 200-25-300 mg	Complera 200-25-300 mg tablet
emtricitabine-tenofovir alafenamide tab 120-15 mg	Descovy 120-15 mg tablet
emtricitabine-tenofovir alafenamide tab 200-25 mg	Descovy 200-25 mg tablet
emtricitabine-tenofovir disoproxil fumarate tab various strengths	Truvada (various strengths)

Enalapril and EnasidenibmixedCovered

enalapril maleate oral solution 1 mg/ml	Epaned oral solution 1 mg/mL
enasidenib mesylate tab 50 mg	Idhifa 50 mg tablet
enasidenib mesylate tab 100 mg	Idhifa 100 mg tablet

Enfuvirtide (Fuzeon)mixedCovered

enfuvirtide for injection 90 mg

Fuzeon 90 mg injection

Ensartinib (Ensacove)mixedCovered

ensartinib HCl cap 25 mg	Ensacove 25 mg capsule
ensartinib HCl cap 100 mg	Ensacove 100 mg capsule

Ensifentrine (Ohtuvayre)mixedCovered

ensifentrine inhalation suspension 3 mg/2.5 ml

Ohtuvayre inhalation suspension 3 mg per 2.5 mL

Entrectinib (Rozlytrek)mixedCovered

entrectinib cap 100 mg	Rozlytrek 100 mg capsule
entrectinib cap 200 mg	Rozlytrek 200 mg capsule
entrectinib pellet pack 50 mg	Rozlytrek 50 mg pellet pack

Enzalutamide (Xtandi)mixedCovered

enzalutamide cap/tab 40 mg	Xtandi 40 mg capsule/tablet
enzalutamide tab 80 mg	Xtandi 80 mg tablet

Erdafitinib (Balversa)mixedCovered

erdafitinib tab 3 mg	Balversa 3 mg tablet
erdafitinib tab 4 mg	Balversa 4 mg tablet
erdafitinib tab 5 mg	Balversa 5 mg tablet

Billing and pharmacy actions — what providers and pharmacies must do

Billing Rule

Adhere to product-specific dispensing limits

Pharmacies must not dispense more than the stated quantity for each listed product within the specified time period; cumulative limits across agents apply where noted (e.g., topical corticosteroids).

Cumulative limits across agents are explicitly noted in product lines (e.g., "100/30 cumulative across agents").

Documentation Required

Cumulative quantity tracking

Where the policy indicates cumulative limits across agents (for example '100/30 cumulative across agents'), pharmacies and payers must track cumulative quantities across the specified agent group within the time window.

Topical corticosteroids: examples showing 100 g per 30 days cumulative across agents (e.g., amcinonide, betamethasone, clobetasol, desoximetasone, etc.).

Quantitative thresholds & cumulative limits

Terminology and designations

Operational FAQs and member/provider queries

Common Q&A

Pharmacy quick-reference

Document changes

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyDispensing Limits Performance Select Ok

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders or members should verify plan-specific dispensing limits and exclusions via plan materials or by calling the number on the member's ID card.

SourceLink

On This Page

abacavir-dolutegravir-lamivudine tab for oral sus 60-5-30 mg (Triumeq Pd) — Dispensing Limit = 180 Tablets Per 30 DAYS. Designation: B.

abaloparatide subcutaneous soln pen-injector 3120 mcg/1.56ml (Tymlos) — Dispensing Limit = 1.56 mLs Per 30 DAYS; 1.56 mLs = 1 injection. Designation: B.

abatacept subcutaneous soln auto-injector 125 mg/ml (Orencia Clickject) — Dispensing Limit = 4 Syringes Per 28 DAYS. Designation: B.

abatacept subcutaneous soln prefilled syringe (Orencia) — Dispensing Limit = 4 Syringes Per 28 DAYS. Designation: B.

abatacept subcutaneous soln prefilled syringe 50 mg/0.4ml (Orencia) — Dispensing Limit = 4 Syringes Per 28 DAYS. Designation: B.

abatacept subcutaneous soln prefilled syringe 87.5 mg/0.7ml (Orencia) — Dispensing Limit = 4 Syringes Per 28 DAYS. Designation: B.

abemaciclib tab 100 mg (Verzenio) — Dispensing Limit = 60 Tablets Per 30 DAYS. Designation: B.

abemaciclib tab 150 mg (Verzenio) — Dispensing Limit = 60 Tablets Per 30 DAYS. Designation: B.

abemaciclib tab 200 mg (Verzenio) — Dispensing Limit = 60 Tablets Per 30 DAYS. Designation: B.

abemaciclib tab 50 mg (Verzenio) — Dispensing Limit = 60 Tablets Per 30 DAYS. Designation: B.

abiraterone acetate micronized tab 125 mg (Yonsa) — Dispensing Limit = 120 Tablets Per 30 DAYS. Designation: B.

abiraterone acetate tab 250 mg (Zytiga) — Dispensing Limit = 120 Tablets Per 30 DAYS. Designation: BG.

abiraterone acetate tab 500 mg (Zytiga) — Dispensing Limit = 60 Tablets Per 30 DAYS. Designation: BG.

abrocitinib tab 100 mg (Cibinqo) — Dispensing Limit = 30 Tablets Per 30 DAYS. Designation: B.

abrocitinib tab 200 mg (Cibinqo) — Dispensing Limit = 30 Tablets Per 30 DAYS. Designation: B.

abrocitinib tab 50 mg (Cibinqo) — Dispensing Limit = 30 Tablets Per 30 DAYS. Designation: B.

acalabrutinib maleate tab 100 mg (Calquence) — Dispensing Limit = 60 Tablets Per 30 DAYS. Designation: B.

aclidinium br-formoterol fum aero pow br act 400-12 mcg/act (Duaklir Pressair) — Dispensing Limit = 1 Inhaler Per 30 DAYS. Designation: B.

aclidinium bromide aerosol powd breath activated 400 mcg/act (Tudorza Pressair) — Dispensing Limit = 1 Inhaler Per 30 DAYS. Designation: B.

acoltremon ophth soln 0.003% (Tryptyr) — Dispensing Limit = 60 Vials Per 30 DAYS. Designation: B.

acoramidis hcl tab pack 356 mg (Attruby) — Dispensing Limit = 112 Tablets Per 28 DAYS. Designation: B.

acyclovir buccal tab 50 mg (Sitavig) — Dispensing Limit = 2 Tablets Per 180 DAYS. Designation: B.

acyclovir-hydrocortisone cream 5-1% (Xerese) — Dispensing Limit = 5 Grams Per 30 DAYS. Designation: B.

adagrasib tab 200 mg (Krazati) — Dispensing Limit = 180 Tablets Per 30 DAYS. Designation: B.

adalimumab products (Humira and biosimilars) — dispensing limits vary by presentation; examples include: auto-injector kit (Humira pen) — 1 Kit Per 180 DAYS (Designation: B); auto-injector pens — 2 Pens Per 28 DAYS (Designation: B); certain starter kits or pediatric starter packs — 1 Kit Per 180 DAYS (Designation: B); prefilled syringe kits (various strengths) — commonly 2 Syringes Per 28 DAYS or 1 Kit Per 180 DAYS depending on pack; adalimumab-aacf presentations — 1 Kit Per 28 DAYS or 1 Kit Per 180 DAYS depending on starter vs maintenance pack (Designation: B).

Adalimumab (Humira) and biosimilars — examples of kit/syringe/pen limits: 1 Kit Per 180 DAYS, 2 Pens Per 28 DAYS, or 2 Syringes Per 28 DAYS depending on presentation; some starter kits limited to 1 Kit Per 180 DAYS. Designation: B.

Oral oncology and specialty tablets

Abemaciclib (Verzenio) — 60 Tablets Per 30 DAYS for 50, 100, 150, 200 mg strengths. Designation: B.
Abiraterone acetate (Yonsa, Zytiga) — 120 Tablets Per 30 DAYS (125 mg, 250 mg) and 60 Tablets Per 30 DAYS (500 mg) as listed. Designation: B or BG per product.
Adagrasib (Krazati) — 180 Tablets Per 30 DAYS. Designation: B.

Ophthalmic & topical

Acoltremon ophthalmic solution (Tryptyr) — 60 Vials Per 30 DAYS. Designation: B.
Acyclovir-hydrocortisone cream (Xerese) — 5 Grams Per 30 DAYS. Designation: B.

Respiratory inhalers

Aclidinium-containing inhalers (Duaklir, Tudorza) — Dispensing Limit = 1 Inhaler Per 30 DAYS. Designation: B.

Other specialty

Acoramidis (Attruby) pack — Dispensing Limit = 112 Tablets Per 28 DAYS. Designation: B.
Acyclovir buccal (Sitavig) — Dispensing Limit = 2 Tablets Per 180 DAYS. Designation: B.

Oral triptans: cumulative maximum of 18 tablets per 30 days across all agents (see multiple triptan entries).

Insulin syringes: QL cumulative for all insulin syringes (300 syringes per 30 days).

Billing Rule

Member responsible for quantity above limit

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

Member is responsible for cost beyond coverage limits; verify plan-specific limits via plan materials or member services prior to dispensing.

Billing Rule

GLP-1 injectable fill limit

Fill limit: only one injectable GLP-1 agent and one strength may be filled per 28 days; a refill window applies.

Codes / examples: exenatide (Bydureon, Byetta, Exenatide) — listed presentations include exenatide extended release auto-injector (Bydureon Bcise) and exenatide pen-injector (Byetta/Exenatide).

Billing Rule

Cumulative triptan limit enforcement

The cumulative quantity limit for oral triptans and triptan combinations is a maximum of 18 tablets per 30 days across all oral triptan agents; pharmacies must enforce the cumulative count across products.

Triptan threshold: Maximum of 18 tablets per 30 days across all oral triptans (examples: almotriptan 18/30, eletriptan 18/30, frovatriptan 18/30, zolmitriptan 18/30, rizatriptan 18/30, sumatriptan 18/30).

Documentation Required

Follow billing units guidance for cartridges/vials

Some products include billing unit guidance (packaging equivalencies or specific billing volumes) that must be used when submitting claims.

Follitropin beta cartridges: specified cartridge counts with each cartridge billed as a specific mL (e.g., 300 unit cartridge billed as 0.420 mL; 600 unit billed as 0.780 mL; 900 unit billed as 1.170 mL).
Follitropin alfa pens/cartridges: entries list pens per 30 days and note billing volumes.
Cartridges/vials billing volumes: many injectable cartridges/vials show 'Each cartridge billed as X mL' or equivalent and must be billed per that volume.

Documentation Required

Follow brand/generic designation

Pharmacies must follow the listed product designation (BG, B, G) when determining allowable dispenses and substitutions; brand/generic designation affects dispensing and adjudication for many products.

Examples where designation affects dispensing: many product lines show BG/B/G (e.g., abacavir entries, dupilumab syringe volumes with Brand = B, GLP‑1 entries noting brand status), and code group entries explicitly note BG/B/G.
When designation is 'B' (brand only), substitutions to generics are not permitted per the listed policy lines.