CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Enhanced Dispensing Limits (DL)

Defines quantity and time-based dispensing limits applied to covered medications (brand and generics) for pharmacy benefit members of participating BCBS plans; affects prescribers, pharmacists, and members covered by these plans.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyEnhanced Dispensing Limits (DL)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify plan materials or call the number on the member ID to confirm plan-specific dispensing limits and exceptions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipledrug-specific dispensing limits listed

examples: 28/30/90/180/365time windows shown

30/30common tablet limit

2 Pens/28Dadalimumab common limit

100 mLinsulin per-30-day limit

>=100

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage / Dispensing Limits

Product dispensing limits (partial list)

The following list contains product-specific dispensing limits and the brand/generic applicability. Products are covered when dispensed at or below the stated quantity and timeframe. Requests that exceed these limits may require prior authorization or may not be covered; check member plan documents or call the number on the ID card for plan-specific exceptions.

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

abacavir sulfate tab 300 mg (Ziagen) — Dispensing Limit: 60 Tablets Per 30 DAYS; Coverage indicator: BG.

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

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

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

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

abatacept for iv soln 250 mg (Orencia) — Dispensing Limit: 4 Vials Per 28 DAYS; Coverage indicator: B.

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

abatacept subcutaneous soln prefilled syringe (Orencia) — Dispensing Limit: 4 Syringes Per 28 DAYS; Coverage indicator: B.

abemaciclib tab (Verzenio) — Dispensing Limit: 60 Tablets Per 30 DAYS across strengths (50,100,150,200 mg); Coverage indicator: B.

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

abiraterone acetate tab 250 mg (Zytiga) — Dispensing Limit: 120 Tablets Per 30 DAYS; Coverage indicator: BG.

abiraterone acetate tab 500 mg (Zytiga) — Dispensing Limit: 60 Tablets Per 30 DAYS; Coverage indicator: BG.

abrocitinib tab (Cibinqo) — Dispensing Limit: 30 Tablets Per 30 DAYS across strengths (50,100,200 mg); Coverage indicator: B.

acalabrutinib maleate tab 100 mg (Calquence) — Dispensing Limit: 60 Tablets Per 30 DAYS; Coverage indicator: B.

aclidinium bromide / formoterol (Duaklir Pressair) — Dispensing Limit: 1 Inhaler Per 30 DAYS; Coverage indicator: B.

acoltremon ophthalmic soln 0.003% (Tryptyr) — Dispensing Limit: 60 Vials Per 30 DAYS; Coverage indicator: B.

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

acyclovir buccal tab 50 mg (Sitavig) — Dispensing Limit: 2 Tablets Per 180 DAYS; Coverage indicator: B.

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

adagrasib tab 200 mg (Krazati) — Dispensing Limit: 180 Tablets Per 30 DAYS; Coverage indicator: B.

adalimumab auto-injector kit (Humira starter kits) — Dispensing Limit: 1 Kit Per 180 DAYS; Coverage indicator: B.

cabozantinib s-malate tab 40 mg & 60 mg (Cabometyx) — Dispensing Limit: 30 Tablets Per 30 DAYS; Coverage indicator: B.

calcifediol cap er 30 mcg (Rayaldee) — Dispensing Limit: 60 Capsules Per 30 DAYS; Coverage indicator: B.

calcipotriene topical formulations (foam, cream, ointment, suspensions) — Dispensing Limit: 120 Grams or 120 Grams/120 mLs Per 30 DAYS depending on formulation; Coverage indicator: B (product-specific noted).

calcipotriene-betamethasone dipropionate topical (Wynzora, Enstilar, Taclonex) — Dispensing Limit: 120 Grams Per 30 DAYS; Coverage indicator: B or BG as specified per product.

canagliflozin (Invokana) and canagliflozin-metformin combinations (Invokamet, Invokamet XR) — Dispensing Limit: 30–60 Tablets Per 30 DAYS depending on product; Coverage indicator: B.

capivasertib (Truqap) — Dispensing Limit: 64 Tablets Per 28 DAYS across listed strengths/therapy packs; Coverage indicator: B.

caplacizumab-yhdp for inj kit 11 mg (Cablivi) — Dispensing Limit: 58 Kits Per 365 DAYS; Coverage indicator: B.

capmatinib (Tabrecta) — Dispensing Limit: 112 Tablets Per 28 DAYS across listed strengths; Coverage indicator: B.

carbinoxamine maleate tab — Dispensing Limit: 150 Tablets Per 30 DAYS; Coverage indicator: BG.

cariprazine (Vraylar) — Dispensing Limit: 30 Capsules Per 30 DAYS across strengths; Coverage indicator: B.

celecoxib (Celebrex) formulations — Dispensing Limit: typically 60 Capsules Per 30 DAYS (400 mg strength 30 per 30 days); Coverage indicator: BG or B for oral solution (Elyxyb) as noted.

cenegermin-bkbj ophthalmic soln 0.002% (Oxervate) — Dispensing Limit: 56 Vials Per 112 DAYS; Coverage indicator: B.

ceritinib tab 150 mg (Zykadia) — Dispensing Limit: 90 Tablets Per 30 DAYS; Coverage indicator: B.

certolizumab pegol (Cimzia) — Dispensing Limit: 1–4 Kits/Syringes Per 28 or 180 DAYS depending on kit; Coverage indicator: B.

cetrorelix acetate for inj kit 0.25 mg (Cetrotide) — Dispensing Limit: 12 Kits Per 30 DAYS; Coverage indicator: BG.

chenodiol tab 250 mg (Ctexli) — Dispensing Limit: 90 Tablets Per 30 DAYS; Coverage indicator: B.

chlordiazepoxide hcl-clidinium bromide (Librax) — Dispensing Limit: 240 Capsules Per 30 DAYS; Coverage indicator: BG.

chlorzoxazone tabs — Dispensing Limit: 120 Tablets Per 30 DAYS; Coverage indicator: G.

cladribine (Mavenclad) tab therapy packs — Product-specific dispensing limits per 301 DAYS (various pack sizes) with Coverage indicator: B.

clarithromycin ER 500 mg — Dispensing Limit: 28 Tablets Per 180 DAYS; Coverage indicator: G.

clindamycin phosphate soln 1% — Dispensing Limit: 180 mLs Per 30 DAYS; Coverage indicator: G.

clobetasol propionate topical agents — Dispensing Limits vary (100 g Per 30 DAYS cumulative across agents; 180 g Per 90 DAYS cumulative across agents; lotions/sprays mL limits noted); Coverage indicators vary by product (B, BG, G).

ciclopirox topical formulations — Dispensing Limits: 180 Grams or 180 mLs Per 30 or 90 DAYS per formulation; Coverage indicator: G or BG as specified.

clotrimazole and related antifungals — product-specific limits as listed; follow per-product values above.

clozapine formulations — Dispensing Limits vary by strength and formulation (e.g., ODT and tables up to 270 Tablets Per 30 DAYS or 540 mLs Per 30 DAYS for suspension); Coverage indicators: G or B/BG depending on product.

coagulation factor IX recombinant products — Dispensing Limit: typically 1 mL Per 30 DAYS for multiple brands; Coverage indicator: B.

coagulation factor VIIa (Sevenfact) — Dispensing Limit: 1 mL Per 30 DAYS; Coverage indicator: B.

cobicistat tab 150 mg (Tybost) — Dispensing Limit: 30 Tablets Per 30 DAYS; Coverage indicator: B.

cobimetinib (Cotellic) — Dispensing Limit: 63 Tablets Per 28 DAYS; Coverage indicator: B.

continuous glucose monitoring sensors/receivers/transmitters (Dexcom, FreeStyle Libre) — Dispensing Limits: sensors 2–3 per 28–30 DAYS; receiver 1 Per 365 DAYS; transmitter 1 Per 90 DAYS; Coverage indicator: B.

crinecerfont (Crenessity) formulations — Dispensing Limits: capsules 60 Per 30 DAYS, oral soln 120 mLs Per 30 DAYS; Coverage indicator: B.

crizotinib (Xalkori) formulations — Dispensing Limits: 120–180 Capsules Per 30 DAYS depending on presentation; Coverage indicator: B.

cromolyn sodium nebu 20 mg/2ml — Dispensing Limit: 240 mLs Per 30 DAYS; Coverage indicator: G.

crotamiton lotion 10% — Dispensing Limit: 454 Grams Per 30 DAYS; Coverage indicator: B.

cyclobenzaprine ER (Amrix) caps — Dispensing Limit: 30 Capsules Per 30 DAYS; Coverage indicator: BG.

cyclosporine ophthalmic emulsions (Restasis, Klarity-C, Verkazia, Cequa, Vevye) — Dispensing Limits vary (e.g., 60 Vials Per 30 DAYS, 1 Bottle Per 30 DAYS, 120 Vials Per 30 DAYS); Coverage indicator: B or BG as specified.

dabigatran (Pradaxa) formulations — Dispensing Limits: 60–120 Capsules Per 30 DAYS depending on strength/packaging; Coverage indicator: BG.

fluticasone and combination inhaled products (Breo Ellipta, Flovent Diskus, Armonair Digihaler, Advair/Airduo, Trelegy Ellipta) — Dispensing Limits vary by product (1 Inhaler Per 30 DAYS, 60–240 Blisters Per 30 DAYS, etc.); Coverage indicator: B.

follitropin alfa/beta products (Gonal-F, Follistim) — Dispensing Limits: variable (pens, vials, cartridges) per 30 DAYS with specific vial/cartridge counts and billing notes; Coverage indicator: B.

fosamprenavir, fostamatinib, fostemsavir, fremanezumab (Ajovy) — Dispensing Limits and coverage indicators as listed (e.g., fremanezumab 3 devices Per 84 DAYS); Coverage indicator: B.

frovatriptan and oral triptans — Quantity limit cumulative across agents: maximum 18 tablets Per 30 DAYS across all oral triptans; Coverage indicator: BG for frovatriptan.

gabapentin (Gralise and other ER forms) and gabapentin enacarbil (Horizant) — Dispensing Limits: typically 30–90 Tablets Per 30 DAYS depending on strength; Coverage indicator: BG or B as specified.

galcanezumab (Emgality) — Dispensing Limits: 1 Injection Device Per 28 DAYS or 9 Syringes Per 180 DAYS depending on presentation; Coverage indicator: B.

garadacimab (Andembry), gefitinib (Iressa), gentamicin topical — Dispensing limits and coverage indicators as listed (B or BG or G).

gepirone (Exxua) formulations, gilteritinib (Xospata), givinostat (Duvyzat), glasdegib (Daurismo), glatiramer acetate (Copaxone) — Product-specific dispensing limits and coverage indicators as listed (typically B).

glecaprevir-pibrentasvir (Mavyret) — Dispensing Limits: pellet packs/tabs per 28–30 DAYS as listed; Coverage indicator: B.

glucose blood test strips (D-Care) — Dispensing Limit: 204 Strips Per 30 DAYS; Coverage indicator: B.

glycopyrrolate-formoterol (Bevespi Aerosphere) — Dispensing Limit: 1 Inhaler Per 30 DAYS; Coverage indicator: B.

glycopyrronium tosylate pads (Qbrexza) — Dispensing Limit: 30 Pads Per 30 DAYS; Coverage indicator: B.

golimumab (Simponi) — Dispensing Limit: 1 Syringe Per 28 DAYS; Coverage indicator: B.

guanfacine ER (Intuniv) — Dispensing Limit: 30 Tablets Per 30 DAYS across strengths; Coverage indicator: BG.

guselkumab (Tremfya) — Dispensing Limits: induction packs, pens, syringes varying from 1 Pen/Syringe Per 28–56 DAYS or 3 Kits Per 180 DAYS; Coverage indicator: B.

halcinonide topical agents, halobetasol propionate topical agents and combination products — Dispensing Limits: product- and cumulative-agent limits apply (e.g., 90 g Per 30 DAYS with 100/30 cumulative; 150–180 g Per 90 DAYS with 180/90 cumulative); Coverage indicators: BG or B or G as specified.

hydrochlorothiazide for susp (Inzirqo) — Dispensing Limit: 160 mLs Per 30 DAYS; Coverage indicator: B.

hydrocodone bitartrate ER formulations — Dispensing Limits: typically 60 Capsules Per 30 DAYS for ER strengths; Coverage indicator: B.

hydrocodone bitartrate tab ER 24hr deter 100 mg (Hysingla ER) — Dispensing Limit: 30 Tablets Per 30 DAYS; Coverage indicator: BG.

insulin and insulin-related supplies (multiple listed products) — Dispensing Limits: insulin vials and pens generally 100 mLs Per 30 DAYS; pumps and devices have kit limits per 720 DAYS or supply-period limits; pen needles, syringes and pods limits often 300 units/needles or 30 pods Per 30 DAYS; many items note cumulative quantity limits across similar items; Coverage indicator: B for listed insulin products and supplies.

interferon beta products — Dispensing Limits vary by product/pack (e.g., 14 Vials Per 28 DAYS, 1 Kit Per 28 DAYS, 12 Syringes Per 28 DAYS) with QL cumulative across strengths; Coverage indicator: B.

ivacaftor (Kalydeco) — Dispensing Limit: 60 Tablets Per 30 DAYS; Coverage indicator: B.

ivermectin cream 1% (Soolantra) — Dispensing Limit: 45 Grams Per 30 DAYS; Coverage indicator: BG.

ivosidenib (Tibsovo) — Dispensing Limit: 60 Tablets Per 30 DAYS; Coverage indicator: B.

ixazomib (Ninlaro) — Dispensing Limit: 3 Capsules Per 28 DAYS; Coverage indicator: B.

ixekizumab (Taltz) — Dispensing Limit: 1 Syringe Per 28 DAYS; Coverage indicator: B.

lanadelumab (Takhzyro) — Dispensing Limit: 2 Syringes Per 28 DAYS; Coverage indicator: B.

lansoprazole formulations — Dispensing Limit: 60 Capsules/Tabs Per 30 DAYS for listed products; Coverage indicator: G or BG as specified.

lanthanum carbonate chew tabs (Fosrenol) — Dispensing Limit: 360 Tablets Per 365 DAYS; Coverage indicator: (elemental) as listed.

Coding, Codes & Key Limits

Prescriber & Pharmacist Actions, Prior Authorization & Denial Risk

Note

Verify plan- or state-specific exceptions

Some dispensing limits may not apply to all members and can vary by state or benefit plan; verify plan materials or call the number on the back of the member’s ID card to confirm any exceptions or exclusions.

Plan- or state-specific variations may affect whether a listed dispensing limit applies to a member.

Prior Authorization

Dispensing limits determine authorization handling

Dispensing limits are specified per specialty agent (e.g., alirocumab: 2 pens per 28 days) and govern how much may be dispensed without an exception; quantities beyond those limits invoke payer limit/authorization processes.

Example: alirocumab auto-injector = 2 pens per 28 days (Praluent).

Prior Authorization

Policy Background

Background: Dispensing limits are administrative controls intended to encourage medication use consistent with FDA labeling and to limit quantities dispensed per prescription or per time period. The policy emphasizes these limits govern coverage adjudication (e.g., per-product caps and cumulative limits) and that members/providers should verify plan-specific applicability.

Key Definitions & Notations

Dispensing Limit (definition)

Definition - Dispensing LimitQuantity allowed to be dispensed/covered per specified time period (e.g., tablets per 30 days, vials per 28 days)

PurposeAdministrative control to align dispensing with labeling and plan rules

EffectRequests exceeding limits may be denied or require prior authorization; members may be financially responsible for excess

BG/B/G flags

BG/B/G flagsNotation indicating whether the limit applies to Brand and Generic (BG), Brand only (B), or Generic only (G)

UsageShown per product entry to indicate applicability to branded or generic forms

Class Limits & Step Controls

Criteria	Limit
Cumulative maximum across class (oral triptans)
Covered up to a maximum of 18 tablets per 30 days across all oral triptan agents

Per-Product Quantity Limits (Selected Entries)

abacavir sulfate soln 20 mg/ml (Ziagen)

abacavir sulfate soln 20 mg/ml (Ziagen)960 mLs per 30 DAYS

Brand/Generic flagListed as BG where noted

Claim noteApply per-product limit on claims adjudication

abacavir sulfate tab 300 mg (Ziagen)

abacavir sulfate tab 300 mg (Ziagen)60 Tablets per 30 DAYS

ApplicabilityListed with BG designation where indicated

EnforcementDispensing above 60/30 may require authorization or be denied

Additional Per-Product Quantity Limits (Selected)

Insulin Products, Pumps, Cartridges & Supplies

Selected per-product limits (A–G)

Additional per-product limits (H–Z)

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyEnhanced Dispensing Limits (DL)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify plan materials or call the number on the member ID to confirm plan-specific dispensing limits and exceptions.

SourceLink

On This Page

Prior authorization implied for override requests

When a prescriber requests quantities that exceed a product’s listed dispensing limit, prior authorization or an override is implied to be required to allow the excess quantity.

The policy notes explicit per-period dispensing limits which imply a prior authorization or override is required to exceed those limits.

Documentation Required

Follow product- and strength-specific limits

Dispensing limits are enforced at the product/strength level (e.g., avapritinib = 30 tablets per 30 days; azithromycin = 60 tablets per 180 days); prescriptions must conform to the listed formulation/strength to apply the specific limit.

Avapritinib: 30 tablets per 30 days.
Azithromycin: 60 tablets per 180 days (cumulative across strengths).

Denial Risk

Exceeding product limits may cause denial

Quantities dispensed that exceed a product’s listed limit may be denied at claim adjudication or require prior authorization; failure to obtain authorization risks coverage denial.

Example: Amrix (cyclobenzaprine ER 15 mg) = 30 capsules per 30 days; Restasis multidose = 1 bottle per 30 days — amounts above these limits will require authorization or be limited at adjudication.

Denial Risk

Claims for quantities above limits risk denial

If a pharmacy claim presents a quantity beyond the stated dispensing limit, adjudication may deny or adjust the claim unless prior authorization/override documentation is provided.

Many insulin products are limited to 100 mLs per 30 days; claims exceeding that may be denied without authorization.

Prior Authorization

Quantity limits (e.g., GLP-1) may require prior authorization

Some medications (notably GLP-1 agents and other specialty therapies) have explicit fill limits and refill-window rules; exceeding the per-period quantity typically requires prior authorization.

Dulaglutide (Trulicity): 4 pens per 28 days with a fill limit of one injectable GLP-1 agent and one strength per 28 days; a refill window applies.

Prior Authorization

PA required to exceed per-period quantity caps

Per-period quantity limits imply prior authorization may be required to exceed the listed per-period totals (e.g., empagliflozin 30 tablets per 30 days would require PA if dispensing above 30).

The document indicates PA implication when dispensing above stated per-period limits.

Prior Authorization

Specialty product limits trigger authorization processes

High-cost specialty products have specific per-period dispensing limits and may require authorization when requests exceed those limits (e.g., evolocumab = 6 pens per 28 days).

Evolocumab (Repatha) auto-injector: 6 pens per 28 days (auto-injector) or 2 cartridges per 30 days (Pushtronex).

Prior Authorization

Use prior authorization for quantities beyond listed limits

Many specialty agents and limited-supply items are listed with per-period limits; prior authorization processes should be used when the requested quantity exceeds the stated limit.

The policy instructs using prior authorization when requested quantity exceeds specified per-period dispensing limits.

Prior Authorization

Obtain prior authorization to exceed specialty agent limits

Numerous specialty agents are limited to specific units per period (e.g., ixazomib 3 capsules per 28 days); obtain prior authorization if the clinician prescribes quantities beyond those listed.

Example: ixazomib (Ninlaro) = 3 capsules per 28 days.

Prior Authorization

PA required for pump kits/devices beyond frequency caps

Insulin pump starter kits and infusion pump devices are limited to specified frequencies (e.g., 1 kit per 720 days); requests for additional kits or devices beyond these limits may require prior authorization.

Omnipod and similar insulin infusion starter kits: 1 kit per 720 days.

Prior Authorization

Authorization needed for limited/high-cost product overages

Certain limited or high-cost products have low per-period dispensing caps and typically require authorization to exceed those caps (e.g., ixazomib, ixekizumab, lanadelumab entries show 28-day caps).

Lanadelumab (Takhzyro): 2 vials or syringes per 28 days; Ixekizumab (Taltz): 1 syringe per 28 days.

Prior Authorization

Authorization required to exceed annual/low-count limits

Products with annual or very low-count limits (e.g., lenacapavir = 4 tablets per 365 days) will likely require authorization to exceed the stated annual limit.

Lenacapavir (Sunlenca/Yeztugo): 4 tablets per 365 days.

Billing Rule

Enforce GLP‑1 single-agent, single-strength 28‑day fill limit

Only one injectable GLP-1 agent and one strength may be filled per 28 days; pharmacies should enforce this single-agent/strength fill rule when dispensing GLP‑1 injectables.

Dulaglutide (Trulicity) examples: 4 pens per 28 days with a fill limit of one GLP‑1 agent and one strength per 28 days.

Billing Rule

GLP‑1 class fill limit: one agent/strength per 28 days

The GLP-1 class fill limit is enforced across products: only one injectable GLP‑1 agent and one strength is allowed per 28 days (applies across specific exenatide and dulaglutide presentations).

Exenatide extended release (Bydureon Bcise) and dulaglutide (Trulicity) entries reference the one-agent/one-strength 28-day rule.

Step Therapy

Cumulative 18‑tablet limit for oral triptans (30 days)

Oral triptans are subject to a cumulative class limit: a maximum of 18 tablets per 30 days across all oral triptan agents; dispense and claims must respect the cumulative cap.

Example: almotriptan listed with 18 tablets per 30 days; the limit is cumulative across oral triptans.

Documentation Required

Verify plan-level dispensing limits with member’s plan

Members should verify plan materials or call the number on their ID card to confirm whether a listed limit applies to their specific plan or state.

Plan materials/ID‑card contact is the source to confirm plan-level applicability.

Documentation Required

Document cumulative topical quantities across agents

Some topical products are limited by cumulative grams per period across multiple agents (e.g., many topical corticosteroids have 100 g per 30 days cumulative caps); document cumulative use when requesting excess.

Amcinonide: 100 grams per 30 days (100/30 cumulative across agents).
Betamethasone: examples include 100 g/30 days and 180 g/90 days cumulative caps.

Documentation Required

Ensure prescriptions and claims conform to listed dispensing limits

Prescriptions must conform to the listed dispensing limit (quantity and days) for the specific formulation and strength; claims should reflect those quantities to avoid adjudication issues.

Claims should match per-product dispensing limits (quantity and timeframe) shown for each NDC/product.

Documentation Required

Provide documented dosing rationale for weight‑based biologics exceeding QL

Some biologic or weight‑based products have documented quantity‑limit calculations (e.g., Haegarda QL based on CDC 90th percentile weight); supporting clinical documentation (weight/dosing rationale) may be required for quantities above the standard limit.

Haegarda: QL calculation based on CDC 90th percentile weight, rounded to even dose; this rationale is documented in the policy.

Documentation Required

Apply cumulative topical limits for desoximetasone formulations

Topical desoximetasone products are limited cumulatively (e.g., cream/gel/ointment/spray to 100 grams or 100 mL per 30 days cumulative across agents); verify formulation and cumulative total when dispensing.

Desoximetasone cream/gel/ointment/spray: 100 grams per 30 days (100/30 cumulative across agents)

Documentation Required

Desoximetasone: 100 g per 30 days cumulative across agents

Desoximetasone examples explicitly state a 100‑gram per 30‑day cumulative cap across agents (desoximetasone cream/gel/ointment/spray); pharmacies should document dispensing against that cumulative cap.

Desoximetasone gel/cream listings: 90–100 grams per 30 days with 100/30 cumulative across agents.

Documentation Required

Document GLP‑1 dispensing and adhere to refill‑window rules

When dispensing GLP‑1 agents, pharmacies should document the dispensed quantity and enforce refill-window rules and the single‑agent/strength fill limit to prevent claims denials.

Dulaglutide and exenatide entries include a fill limit of one injectable GLP‑1 agent and one strength per 28 days and note a refill window.

Billing Rule

Submit claims aligned to listed quantity/time limits

Pharmacy claims must match the listed per‑product dispensing limit (quantity and timeframe) for each NDC/product; inconsistent claims risk rejection or adjustment at adjudication.

Claims should reflect kit limits (e.g., 1 kit per 720 days) and pod limits (30 pods per 30 days) as listed.

Billing Rule

Enforce refill windows and single‑agent fill rules

Refill windows and single‑agent rules apply for some agents (notably GLP‑1 injectables); enforce these operational controls when processing refills.

Examples: GLP‑1 fill limit of one agent/one strength per 28 days; refill window language appears in multiple GLP‑1 entries.

Billing Rule

Include billing details that affect unit counts on claims

Billing notes for certain product lines (for example, follitropin cartridges billed as specific volume) can affect how dispensed units are counted on a claim; include billing details on claim submissions.

Follitropin beta cartridges are billed by specified volume (e.g., 0.420 mL for a 300‑unit cartridge).

Documentation Required

Confirm exact product/formulation before applying limits

The listed quantity limit applies only when the dispensed product matches the exact formulation/strength shown (e.g., insulin formulation/device); confirm product identification to apply the correct limit.

Insulin limits are tied to specific pen/cartridge formulations and are cumulative across injectable formulations when stated.

Billing Rule

Align documentation and claims to dispensing limits

Prescription claims should reflect quantities consistent with stated dispensing limits (e.g., kit limits per 720 days; pod limits per 30 days); claims inconsistent with these limits may be rejected or adjusted.

Omnipod starter kit: 1 kit per 720 days; Omnipod pods: 30 pods per 30 days.

Documentation Required

Follow product dispensing limits (example: Rebidose 12 syringes/28d)

Prescriptions must follow product dispensing limits (for example, Rebif Rebidose is limited to 12 syringes per 28 days); pharmacists should enforce these product‑specific caps.

Rebif Rebidose (interferon beta‑1a): 12 syringes per 28 days; quantity cumulative across strengths.

Billing Rule

Ensure claims match product‑specific period and quantity limits

Pharmacy claims must conform to the product‑specific dispensing limit period and quantity (for example, lansoprazole 15 mg = 60 capsules per 30 days); submit claims accordingly to avoid adjudication issues.

Lansoprazole 15 mg: 60 capsules per 30 days.

Denial Risk

Member may be financially responsible for quantities above limits

If a prescriber writes for a quantity greater than the dispensing limit, the member may still obtain the medication but will be responsible for the full cost beyond coverage limits unless prior authorization is granted.

The policy states members are responsible for full cost beyond coverage if the prescribed quantity exceeds the dispensing limit.

Denial Risk

Requests above per‑period limits may be denied

Requests exceeding the per‑period quantity limits for a specific product (for example, more than 2 pens per 28 days for listed adalimumab products) may be denied at adjudication.

Adalimumab (various biosimilars) commonly limited to 2 pens per 28 days.

Denial Risk

Dispensing beyond listed per‑period quantities risks denial

Dispensing beyond the listed quantity per time period (e.g., more than the specified tablets/capsules/packs per 30 days) may trigger a denial or require an exception/override.

The policy repeatedly notes dispensing beyond listed per‑period amounts may trigger denial or require exception.

Denial Risk

Exceeding listed dispensing limits may lead to denial

Requests exceeding the listed dispensing limit for a given product/strength (e.g., azithromycin 60 tablets per 180 days; betamethasone 100 g per 30 days cumulative across agents) may be denied unless supported by authorization.

Azithromycin: 60 tablets per 180 days (cumulative across strengths).
Betamethasone/amcinonide: 100 g per 30 days cumulative caps across agents.

Denial Risk

Coverage denial risk when per‑product limits are exceeded

Dispensing beyond the per‑product quantity/time limit may trigger coverage denial at claim adjudication if no authorization or exception is documented.

The policy warns that dispensing beyond listed per‑product limits may trigger coverage denial at adjudication.

Prior Authorization

Obtain override/PA to prevent claim denials for overages

Dispensing beyond listed per‑product limits may result in claim denial or require an override; prescribers should request prior authorization before exceeding limits to avoid denials.

Examples include Amrix = 30 capsules per 30 days; Restasis multidose = 1 bottle per 30 days.

Denial Risk

Overages for GLP‑1 pens may be denied without PA

Dispensing beyond per‑period limits (e.g., more than four pens of dulaglutide per 28 days) may trigger denial or require an override—confirm limits before dispensing.

Dulaglutide: 4 pens per 28 days; dispensing more may trigger denial or override requirement.

Denial Risk

Simple numeric exceedances risk denial

Requests exceeding simple numeric limits (e.g., >30 tablets when limit = 30 tablets per 30 days) may be denied by the payer at adjudication.

Policy states requests exceeding listed limits (e.g., >30 tabs where limit = 30/30) may be denied.

Denial Risk

Claims exceeding formulation‑specific caps may be rejected

Claims exceeding specified dispensing limits for listed formulations (e.g., more than 60 packets per 30 days for certain products) may be rejected or limited at point of adjudication.

Evolocumab cartridge Pushtronex example: 2 cartridges per 30 days; claims above this may be rejected.

Denial Risk

Excess inhaler/blister dispensing may trigger denial

Dispensing in excess of listed per‑product limits (e.g., >60 blisters per 30 days, >1 inhaler per 30 days) may trigger a quantity‑limit denial or require an override.

Fluticasone examples: 60 blisters per 30 days or 1 inhaler per 30 days depending on presentation.

Denial Risk

Adjudication denial risk for product/formulation overages

Requests exceeding listed dispensing limits for the specified product/formulation and time period may be denied during adjudication if no authorization is in place.

Examples include halobetasol, hydrocodone ER, and other product‑specific caps.

Denial Risk

Common dispensing overages (insulin/pods/needles) risk denial

Requests exceeding commonly enforced dispensing limits (e.g., >100 mLs per 30 days for many injectable insulins; >30 pods per 30 days for pump reservoirs; >300 pen needles/syringes per 30 days) may be denied without prior authorization.

Insulin examples: 100 mLs per 30 days for many injectable insulins; Omnipod pods = 30 per 30 days; pen needles = 300 per 30 days.

Denial Risk

Overages for syringes/needles risk denial

Requests exceeding insulin‑supply limits (e.g., >300 insulin syringes per 30 days) or other product‑specific limits may be denied unless prior authorization or justification is provided.

Insulin syringes: 300 syringes per 30 days; QL cumulative across all syringe listings.

Denial Risk

Denial risk when exceeding lanadelumab and similar product limits

Requests exceeding the listed dispensing limits for a product (for example, more than 2 vials per 28 days for lanadelumab 300 mg/2 mL) may be denied during adjudication.

Lanadelumab (Takhzyro): 2 vials or 2 syringes per 28 days.

Some limits may vary by plan/state — confirm plan materials

Cumulative across injectable formulations

Cumulative across injectable formulationsQuantity limits may be cumulative across injectable formulations (e.g., insulin limits noted as cumulative across injectable formulations)

ExampleInsulin degludec and glargine entries note 100 mLs/30d with cumulative across injectables

ImplicationDifferent injectable presentations of same active ingredient count toward a shared cap when specified

BG / B / G indicators

BG / B / G indicators expandedBG = Generic and Brand; B = Brand only; G = Generic only

PlacementIndicator appears after each product line to show applicability

InterpretationLimits and coverage apply according to the stated BG/B/G designation

Quantity limit cumulative (QL cumulative)

Quantity limit cumulative (QL cumulative)Some QLs are cumulative across strengths or formulations (e.g., Rebif Rebidose syringes cumulative across strengths; insulin syringes cumulative across SKUs)

Claim alignmentClaims should represent the exact formulation/strength to apply cumulative rules properly

EnforcementCumulative counts are used at adjudication and may trigger denials if exceeded

abaloparatide pen-injector (Tymlos)

abaloparatide pen-injector (Tymlos)1.56 mLs per 30 DAYS (1 injection)

Unit note1.56 mLs equals one injection/pen fill as listed

Brand statusListed as B (brand) in entries

abatacept IV 250 mg (Orencia)

abatacept IV 250 mg (Orencia)4 Vials per 28 DAYS

Also listed4 Syringes per 28 DAYS for SC presentations

Brand statusListed as B (brand)

abemaciclib tablets (Verzenio)

abemaciclib tablets (Verzenio)60 Tablets per 30 DAYS

StrengthsApplies across listed strengths (50/100/150/200 mg)

Brand statusListed as B (brand)

adalimumab auto-injector kits (various)

adalimumab auto-injector kits (various)1 Kit per 180 DAYS or 2 Pens/Syringes per 28 DAYS depending on formulation

ExamplesHumira starter kits limited to 1 kit/180 days; many biosimilars 2 pens/28 days

Provider noteLimit varies by specific product presentation—apply the listed rule for the exact formulation

adalimumab-aqvh (Yusimry)

adalimumab-aqvh (Yusimry)2 Pens per 28 DAYS

Brand statusListed as B in entry

Applies toAuto-injector presentation 40 mg/0.8 mL

adalimumab-atto (Amjevita)

adalimumab-atto (Amjevita)2 Pens per 28 DAYS (or 2 Syringes for prefilled syringe presentations)

PresentationsIncludes 40 mg/0.4 mL and other pen/syringe sizes listed

Brand statusListed as B

adalimumab-bwwd (Hadlima Pushtouch)

adalimumab-bwwd (Hadlima Pushtouch)2 Pens per 28 DAYS (also 2 Syringes per 28 DAYS for prefilled syringe forms)

FormulationsAuto-injector and prefilled syringe versions listed with same pen/syringe limits

Brand statusListed as B

adapalene pads 0.1%

adapalene pads 0.1%28 Pads per 28 DAYS

Brand statusListed as B in entry

ApplicabilityPer-pad count limit as listed

afatinib dimaleate tablets (Gilotrif)

afatinib dimaleate tablets (Gilotrif)30 Tablets per 30 DAYS

StrengthsApplies to multiple strengths (20/30/40 mg) as listed

Brand statusListed as B

albuterol inhalers

albuterol inhalers2 Inhalers per 30 DAYS

Nebulizer solution120–125 vials or specified mL per 30 DAYS depending on concentration

Brands/formsIncludes HFA and Respiclick/Digihaler presentations

albuterol nebulizer solution

albuterol nebulizer solution120-125 Vials (or specified mLs) per 30 DAYS depending on concentration

Examples0.083%: 125 vials/30d; other concentrations listed similarly

ApplicabilityPer formulation concentration as listed

albuterol-budesonide (Airsupra)

albuterol-budesonide (Airsupra)3 Inhalers per 30 DAYS

Brand statusListed as B

Formulation noteApplies to the specified aerosol presentation

alirocumab (Praluent) auto-injector

alirocumab (Praluent) auto-injector2 Pens per 28 DAYS

Package note1 package = 2 mLs = 2 pens

Brand statusListed as B

almotriptan malate tablets

almotriptan malate tablets18 Tablets per 30 DAYS (cumulative across oral triptans)

Strengths6.25 mg and 12.5 mg presentations listed with same cumulative cap

EnforcementCumulative across class; >18/30 may be denied

alpelisib tablet packs (Piqray)

alpelisib tablet packs (Piqray)28–56 Tablets per 28 DAYS (pack-dependent)

Pack typesDaily-dose packs (200/250/300 mg) have either 28 or 56 tablet limits as listed

Brand statusListed as B

alprostadil products (Caverject, Edex, Muse)

alprostadil products (Caverject, Edex, Muse)4–8 doses/kits per 30 DAYS depending on product

ExamplesCaverject 8 doses/30d; Edex kits 4 kits/30d; Muse pellets 8 doses/30d

Brand statusListed as B for many entries

amcinonide topical formulations

amcinonide topical formulations100 Grams per 30 DAYS

Cumulative note100 g/30d cumulative across agents when specified

Brand statusListed as B for many entries

amifampridine (Firdapse)

amifampridine (Firdapse)300 Tablets per 30 DAYS

Brand statusListed as B

EnforcementPer-product limit enforced at adjudication