CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Balanced Dispensing Limits (DL)

Lists drug-specific dispensing limits (quantity and time period) for covered brand and generic medications and explains member financial responsibility when prescriptions exceed those limits; applies to Blue Cross and Blue Shield of Oklahoma pharmacy benefits and affected members.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyBalanced Dispensing Limits (DL)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPharmacies must adhere to the listed product-specific dispensing limits and document dispensed quantity and date ranges to support claims within limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+distinct products listed (partial)

30 dayscommon dispensing period

30typical tablets per 30 days

2injectable pens/syringes per 28 days

100insulin ml per 30 days

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Product dispensing limits

Coverage is subject to product-specific dispensing limits and brand/generic designation as listed below.

Product-level dispensing rules: Each listed product has an explicit dispensing limit (quantity and time period) and a designation indicating whether brand, generic, or both are allowed (B, G, BG).see product entries

This excerpt contains only a partial product list.

Dispensing limits (by product)

Coverage is limited to the specified quantities per time period for each listed product.

Per-product dispensing limit: Each listed product is subject to the stated dispensing limit (examples include '1 Inhaler Per 30 DAYS' for inhalers, '4 Pens Per 28 DAYS' for some injectables, and '60 Tablets Per 30 DAYS' for select oral agents).as listed per product

See individual product entries for exact quantities and timeframes

General dispensing limits

Coverage is limited to the specified dispensing limits and brand/generic flags for each listed product.

Per-product dispensing rules: Each listed product is covered only up to the specified quantity in the given time period and according to the BG/B/G flag indicating brand/generic coverage.see per-line entries

Individual line items specify exact quantities and coverage flags.

Dispensing quantity limits

Covered when dispensed within the listed quantity limits per 30 days

Insulin solution and pen injectors: Specific insulin products (for example, many aspart, lispro, glargine, degludec formulations) have a dispensing limit of 100 mLs per 30 days; quantity limits are cumulative across injectable formulations where noted.100 mLs per 30 days

Applies to named insulin products in the list.

Afrezza inhalation cartridges: Afrezza inhalation powder cartridges have product-specific per-30-day limits with values varying by cartridge size (examples include 900, 1080, 1260, 1800, 2520 cartridges per 30 days depending on pack size).varies by cartridge size

Values listed per product entry.

Insulin pen needles (various gauges and lengths) have a cumulative dispensing limit of 300 insulin pen needles per 30 days across all pen needle products.300 pen needles per 30 days cumulative

Some plans may exclude coverage for specific agents or entire drug categories. The source document notes that certain categories (for example, erectile dysfunction agents such as sildenafil/Viagra) may be excluded from coverage and that dispensing limits shown may not apply to all members or may vary by state. Providers should verify member plan materials or call the number on the back of the ID card to confirm plan-specific exclusions or mail-service availability.

If a prescriber writes for a quantity greater than the dispensing limit, the member can obtain the medication but will be responsible for the full cost for the portion that exceeds the coverage limit.

Quantities requested that exceed the listed Dispensing Limit are implicitly outside the covered limits unless an exception or override is obtained. The document lists multiple per-product quantity caps (for example, many oral products limited to 30 Tablets Per 30 DAYS and stimulant products like lisdexamfetamine limited to 30 Tablets Per 30 DAYS), and any supply beyond those caps would not be within the standard dispensing allowance.

Pharmacies should document dispensed quantities and dates to support claims within the listed limits; requests above the limits may require prior authorization or result in member financial responsibility per the payer rules.

This excerpt does not present a formal exclusion list. The provided sections document product-level dispensing limits and brand/generic designations but do not enumerate explicit coverage exclusions beyond the general statement that some plans may exclude particular drug categories.

Where exclusion language is required for plan adjudication, providers should consult full plan materials or payer-specific policy documents because explicit exclusions are not provided in these chunks.

No explicit exclusions are specified in the available excerpt. The listings focus on per-product dispensing limits (for example, topical cumulative gram limits and per-period vial/pack limits) rather than an itemized list of excluded drugs.

Because exclusions are not enumerated here, verify any potential exclusion with the member's plan literature or by contacting the payer directly.

Any request for supply that exceeds the listed per-period quantity (for example, > 100 mLs per 30 days for many insulin solutions or > 1 Receiver Per 365 DAYS for CGM receivers) is not within the stated dispensing limits. Such requests are outside the standard dispensing allowance unless an authorization or exception is granted.

Claims or prescriptions exceeding the per-period caps may be subject to denial or require override/prior authorization in accordance with pharmacy benefit controls.

No explicit exclusions are listed in these chunks. The content documents quantity limits and brand/generic flags for many products but does not list specific drugs that are categorically excluded from coverage in this excerpt.

Providers should not interpret absence of explicit exclusions here to mean none exist — verify plan-specific exclusion policies separately.

This excerpt does not provide clinical coverage criteria or explicit exclusions; it predominantly lists dispensing limits and brand/generic status for individual drugs and devices (for example, insulin products with a 100 mLs Per 30 DAYS limit and pen-needle/syringe cumulative limits).

Coverage determinations beyond these dispensing caps (such as medical necessity rules or clinical criteria) are not specified in the provided chunks and must be referenced from the full policy or plan materials.

The excerpt contains no explicit statements labeling therapies as not medically necessary. The content is limited to dispensing quantity caps and brand/generic designations (for example, gabapentin formulations limited to specific tablet counts), and does not define clinical NMN criteria in these chunks.

Where a supply request exceeds the listed dispensing limits, the request falls outside standard coverage quantities and may require additional review or authorization; that circumstance is the practical boundary for coverage rather than an explicit NMN determination in this excerpt.

There are no specific not medically necessary criteria provided in these excerpts. The policy text focuses on per-product quantity caps (for example, insulin and pump supplies) and states that quantities beyond these limits may not be covered without authorization.

If a prescriber orders quantities above the dispensing limits, members may obtain the medication but could be financially responsible for amounts exceeding coverage; clinical NMN determinations are not included in this partial extract.

Coding, Units and Examples

Sample listed products (continued)NDC|drug_name

dexmethylphenidate hcl cap er 24 hr 20 mg	Dispensing Limit = 30 Capsules Per 30 DAYS; BG
dexmethylphenidate hcl cap er 24 hr 25 mg	Dispensing Limit = 30 Capsules Per 30 DAYS; BG
dexmethylphenidate hcl cap er 24 hr 30 mg	Dispensing Limit = 30 Capsules Per 30 DAYS; BG
dexmethylphenidate hcl cap er 24 hr 35 mg	Dispensing Limit = 30 Capsules Per 30 DAYS; BG
dexmethylphenidate hcl cap er 24 hr 40 mg	Dispensing Limit = 30 Capsules Per 30 DAYS; BG
dexmethylphenidate hcl cap er 24 hr 5 mg	Dispensing Limit = 30 Capsules Per 30 DAYS; BG

Amphetamine derivativesNDC|drug_name

dextroamphetamine sulfate cap er 24hr 10 mg (Dexedrine)	Dispensing Limit = 120 Capsules Per 30 DAYS; BG
dextroamphetamine sulfate cap er 24hr 15 mg (Dexedrine)	Dispensing Limit = 120 Capsules Per 30 DAYS; BG
dextroamphetamine sulfate oral solution 5 mg/5ml	Dispensing Limit = 1800 mLs Per 30 DAYS; G
dextroamphetamine td patch 13.5 mg/9hr (Xelstrym)	Dispensing Limit = 30 Patches Per 30 DAYS; B

Selected topical and specialty agentsNDC|drug_name

dextromethorphan hbr-quinidine sulfate cap 20-10 mg (Nuedexta)	Dispensing Limit = 60 Capsules Per 30 DAYS; B
diclofenac epolamine patch 1.3% (Flector)	Dispensing Limit = 150 Patches Per 30 DAYS; B
diflorasone diacetate cream 0.05%	Dispensing Limit = 100 Grams Per 30 DAYS; 100/30 cumulative across agents; B
dihydroergotamine mesylate hfa nasal aerosol 0.725 mg/act (Trudhesa)	Dispensing Limit = 12 mLs Per 28 DAYS; B

Injectable biologics/GLP-1NDC|drug_name

dulaglutide soln auto-injector 0.75 mg/0.5ml (Trulicity)	Dispensing Limit = 4 Pens Per 28 DAYS; Fill limit of one injectable GLP-1 agent and one strength per 28 days; B
dupilumab subcutaneous soln auto-injector 200 mg/1.14ml (Dupixent)	Dispensing Limit = 2 Pens Per 28 DAYS; 2 pens =2.28 mLs; B

Examples from list (non-exhaustive)mixed

D-Care Blood Glucose

glucose blood test strip, Dispensing Limit = 204 Strips Per 30 DAYS

Example volume-to-injection conversion

Volume-to-injection conversion1.56 mLs = 1 injection

Typical dispensing period threshold

Typical dispensing periodsPer 28 DAYS or Per 30 DAYS or Per 180 DAYS as specified per drug

Example product limits

Syringes/Pens2 syringes/pens Per 28 DAYS (example entries for multiple adalimumab presentations)

Inhalers2 inhalers Per 30 DAYS (multiple albuterol HFA/Respiclick/Digihaler entries)

Tablets30 Tablets Per 30 DAYS (common oral tablet limit example)

Vials120 Vials Per 30 DAYS (example vial-based limits appear in product listings)

Dispensing limit examples

30 Capsules per 30 days example30 Capsules Per 30 DAYS (amphetamines, stimulants listed)

60 Tablets per 30 days example60 Tablets Per 30 DAYS (multiple oral products)

1 mL per 30 days example1 mL Per 30 DAYS (antihemophilic factor and similar injectables)

120 Tablets per 30 days example120 Tablets Per 30 DAYS (several oncology agents shown)

Examples of dispensing thresholds

30 Tablets / 30 DAYS30 Tablets Per 30 DAYS (common oral QL)

60 Tablets / 180 DAYS60 Tablets Per 180 DAYS (azithromycin Z‑Pak examples)

4 Syringes / 28 DAYS4 Syringes Per 28 DAYS (multiple biologic/injectable entries)

1 Inhaler / 30 DAYS1 Inhaler Per 30 DAYS (selected inhaler entries such as Trelegy)

Dispensing time windows

Per 28 DAYSPer 28 DAYS (common for many pens/syringes and some kits)

Per 30 DAYSPer 30 DAYS (most common denominator for tablet, mL, inhaler limits)

Per 90 DAYSPer 90 DAYS (used for selected ophthalmic or specialty topical limits)

Per 365 DAYSPer 365 DAYS (used for devices such as CGM receiver limits)

CGM receiver limit

CGM receiver limit1 Receiver Per 365 DAYS

CGM transmitter limit

CGM transmitter limit1 Transmitter Per 90 DAYS

Typical 30-day dispensing limit

Typical 30-day dispensing windowPer 30 DAYS is the most common dispensing period; exact quantity varies by product (see product entries)

Injectable GLP-1 fill limit

Injectable GLP-1 fill ruleFill limit of one injectable GLP-1 agent and one strength per 28 days

Oral triptan cumulative limit

Oral triptan cumulative capMaximum of 18 tablets per 30 days across all oral triptan agents (cumulative limit)

Oral triptan cumulative limit (duplicate)

Oral triptan cumulative cap (duplicate)Maximum of 18 tablets per 30 days across all oral triptan agents

Eplontersen (Wainua) limit

Eplontersen (Wainua)1 Pen Per 28 DAYS

Injectable GLP-1 agent fill limit

Injectable GLP-1 agent fill rule (repeated)One injectable GLP‑1 agent and one strength per 28 days (applies to Trulicity, exenatide ER, etc.)

Oral triptans cumulative

Oral triptans cumulativeMaximum of 18 tablets per 30 days across all agents (cumulative cap)

Insulin monthly volume

Insulin monthly volume100 mLs Per 30 DAYS for many insulin solutions and pen injectors (e.g., Humalog, Admelog, Lyumjev)

Pump reservoir supply

Pump reservoir supply30 Pods Per 30 DAYS (Omnipod and similar reservoir pods)

Pump kit replacement interval

Pump kit replacement interval1 Kit Per 720 DAYS (insulin infusion pump kits)

Per-30-day dispensing quantity examples

Per-30-day dispensing examples (insulin/supplies)Examples include 100 mLs for many insulin pen/solutions; 300 pen needles or syringes cumulative per 30 days; Afrezza cartridge limits varying by product (900–2520 per 30 days examples)

Insulin syringe dispensing limit

Insulin syringe limit300 Syringes Per 30 DAYS (cumulative across insulin syringe products)

Interferon beta (Betaseron) dispensing limit

Betaseron (interferon beta-) limit14 Vials Per 28 DAYS (Betaseron)

Ixazomib dispensing limit

Ixazomib (Ninlaro) limit3 Capsules Per 28 DAYS

Lenacapavir dispensing limit

Lenacapavir (Sunlenca/Yeztugo)4 Tablets Per 365 DAYS

Example dispensing limits (mixed)

Example dispensing limits (mixed)Examples: 1 Pen Per 28 DAYS; 28 Tablets Per 28 DAYS; 4 Tablets Per 365 DAYS; 60 Tablets Per 30 DAYS

Example product dispensing limits

Sample product limits (examples)lisdexamfetamine 20 mg = 30 Tablets Per 30 DAYS; lorlatinib 25 mg = 120 Tablets Per 30 DAYS; lotilaner ophthalmic solution 0.25% = 1 Bottle Per 42 DAYS

Product-Specific Quantity Limits (Selected Entries)

abacavir sulfate soln (Ziagen) limit

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

abacavir sulfate tab 300 mg (Ziagen) limit

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

abacavir-lamivudine (Epzicom) limit

abacavir sulfate-lamivudine tab 600-300 mg (Epzicom)30 Tablets Per 30 DAYS

abaloparatide (Tymlos) limit

abaloparatide (Tymlos) pen-injector1.56 mLs Per 30 DAYS (1.56 mLs = 1 injection)

abatacept (Orencia Clickject) limit

abatacept subcutaneous auto-injector (Orencia Clickject)4 Syringes Per 28 DAYS

abemaciclib (Verzenio) limit

abemaciclib (Verzenio)60 Tablets Per 30 DAYS

acoltremon (Tryptyr) limit

acoltremon ophthalmic solution (Tryptyr)60 Vials Per 30 DAYS

adalimumab (Humira) kit/pen limits

adalimumab auto-injector kit (Humira pen)1 Kit Per 180 DAYS or 2 Pens Per 28 DAYS depending on product form

adalimumab biosimilars and brands limits

adalimumab biosimilars/brandsTypically 2 Pens or Syringes Per 28 DAYS for many presentations

Albuterol inhaler limits

Albuterol inhalers (HFA/Respiclick/Digihaler)2 Inhalers Per 30 DAYS

Albuterol‑budesonide (Airsupra) limit

Albuterol‑budesonide (Airsupra)3 Inhalers Per 30 DAYS

almotriptan limit

almotriptan oral tablets18 Tablets Per 30 DAYS (cumulative across oral triptans)

amcinonide topical limit

amcinonide topical 0.1%100 Grams Per 30 DAYS (100/30 cumulative across agents)

amifampridine (Firdapse) limit

amifampridine (Firdapse) 10 mg300 Tablets Per 30 DAYS

Mydayis limit

amphetamine‑dextroamphetamine 37.5 mg (Mydayis)30 Capsules Per 30 DAYS

Adderall limits

amphetamine‑dextroamphetamine (Adderall) various strengths60–90 Tablets Per 30 DAYS depending on strength

anakinra (Kineret) limit

anakinra (Kineret) 100 mg/0.67 ml28 Syringes Per 28 DAYS

Antihemophilic factor limit

Antihemophilic factor injectables1 mL Per 30 DAYS

apixaban (Eliquis) limit

apixaban 5 mg (Eliquis)74 Tablets Per 30 DAYS

asciminib (Scemblix) limit

asciminib 100 mg (Scemblix)120 Tablets Per 30 DAYS

aztreonam lysine (Cayston) limit

aztreonam lysine for inhalation (Cayston)1 Kit Per 56 DAYS

azilsartan (Edarbi) limit

azilsartan medoxomil 80 mg (Edarbi)30 Tablets Per 30 DAYS

azithromycin (Zithromax) limit

azithromycin 250 mg (Zithromax/Z‑Pak)60 Tablets Per 180 DAYS (cumulative across strengths)

Provider Actions, Authorization and Documentation

Note

Plan verification and scope

This policy defines dispensing (quantity) limits for specific drugs, devices and supplies. Pharmacy providers must verify member plan specifics (see member ID or call the number on the back of the ID card) before dispensing — some limits vary by plan, state regulation, or mail-service availability.

Quantity limits are specified per product (example: alirocumab 150 mg auto-injector = 2 pens per 28 days; dexcom G6 receiver = 1 receiver per 365 days).
Dispensing limits apply to tablets, capsules, pens, syringes, mLs, kits, sensors, transmitters, cartridges, pumps, and similar units as listed.
Brand/generic availability flags (B, BG, G) accompany each entry; pharmacies must adhere to the indicated brand/generic sourcing.
Some specialty biologic and high-cost agents are listed with low-frequency dispensing (example: caplacizumab = 58 kits per 365 days; infusion pump kits = 1 kit per 720 days), which implies a higher likelihood of prior authorization or medical review.

Billing Rule

Claim conformity, units and fill-window rules

Pharmacies must conform claims and dispensed quantities to the product-specific dispensing limits and any special fill rules. When a prescription or refill exceeds the listed dispensing limit or the allowed time window, the claim may be denied unless an approved exception or prior authorization is in place.

Required claim conformity to dispensing limits: ensure quantity, unit type, and time period on the claim match the listed Dispensing Limit (e.g., '30 Tablets Per 30 DAYS', '1 Kit Per 28 DAYS').
Quantity/unit alignment: align claim units with the policy unit (tablets, pens, syringes, mLs, kits, sensors, pods).
Dispensing limit adherence: pharmacies must adhere to fill limits including cumulative QLs across strengths or related agents (example: oral triptans cumulative maximum = 18 tablets per 30 days).
Refill windows apply where specified (e.g., injectable GLP-1 agents: fill limit of one agent and one strength per 28 days; refill window applies).

Prior Authorization

Prior authorization and quantity exceptions

Dispensing limits may create an authorization boundary. For many specialty or high-cost products, quantities above the listed per-period limit will require prior authorization or clinical review. Providers should initiate PA when prescribing quantities or frequencies that exceed the listed limits.

Quantity-based prior authorization: requests for quantities greater than the limit (for example, >4 pens per 28 days for certain agents, >100 mLs insulin per 30 days, or more than allowed sensors/transmitters per period) may trigger a PA request or denial.
Prior authorization implied for specialty agents: many biologics, oncology and rare-disease treatments listed with low per-period dispensing are treated as Brand Only and commonly require PA for exceptions.
Prior authorization for excess quantity: when prescribers write for quantities beyond the dispensing limit the member may obtain the medication but will be financially responsible for amounts not covered unless an authorization is granted.

Documentation Required

Documentation and special QL calculations

Some entries include special QL calculations or notes that require documentation or clinical justification at the time of PA or claim adjudication. Pharmacies and providers should preserve and submit supporting documentation when requesting overrides.

QL calculation note: certain agents (for example, C1 esterase inhibitors) use weight- or population-percentile–based QL calculations (CDC 90th percentile weight averaged and rounded); see Special Clinical Criteria when submitting for PA.
Required dispensing documentation: document prescribed product, VIAL/pen/syringe counts and associated mLs or IU where applicable; support overrides with clinical notes and relevant dosing calculations.
Dispensing documentation and compliance: for durable devices (e.g., insulin pumps) and long-interval supplies, include device serial/kit identifiers and justification for replacement before the interval expires.

Denial Risk

Denial risk and member financial responsibility

When dispensing is denied or a claim fails adjudication due to exceeding limits, providers and pharmacies should inform members of potential financial responsibility and next steps to request a coverage exception or PA.

Quantity limit denial risk: dispensing beyond listed limits may result in denial at point-of-sale or claims processing.
Quantity limit enforcement: pharmacies must adhere to per-product dispensing limits; exceeding limits may require prior authorization or will be processed as member-pay.
Over-limit dispensing risk: if a member elects to receive quantities beyond limits without an approved PA, they may be responsible for full cost of the excess.
Exceeding dispensing limits may trigger denial: common outcomes include claim denial, retrospective adjustment, or direction to submit PA for exception.

Note

Operational examples and common exceptions

Specific operational requirements and notable examples from the dispensing list that affect provider actions and pharmacy operations.

Fill-limit based utilization control: multiple entries include explicit per-period caps (e.g., insulin pen needles = 300 needles per 30 days cumulative; continuous glucose sensors = 2–3 sensors per specified period; evolocumab 140 mg auto-injector = 6 pens per 28 days).
Low-frequency dispensing entries: high-cost or limited-supply items list long intervals (examples: interferon beta titration kits = 1 kit per 180 days; caplacizumab = 58 kits per 365 days; insulin infusion pump starter kit = 1 kit per 720 days).
Prior auth for pump kits: durable insulin infusion pump kits and some starter kits with long replacement intervals are likely to require PA for replacement before the interval.
Monthly dispensing limits and prior authorization: many agents are limited to X per 30 days (e.g., most oral chronic meds = 30 tablets per 30 days) and exceeding monthly limits typically triggers PA or denial.
Dispensing limits and brand/generic flags (no explicit PA listed): entries include B/BG/G indicators; adhere to the listed sourcing unless an approved exception/PA allows a different product.
Dispensing limits may imply PA: products marked Brand Only with low per-period limits commonly necessitate PA for coverage exceptions. Examples include many biologics, oncology therapies, and cystic fibrosis agents.

OpenPayer

Balanced Dispensing Limits (DL)

Coverage Criteria and Dispensing Limits

Coding, Units and Examples

Product-Specific Quantity Limits (Selected Entries)

Provider Actions, Authorization and Documentation

Background

Definitions and Terms

Revision History and Document Status