CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Performance Dispensing Limits (DL)

Defines quantity and time-period limits for covered prescription drugs for Blue Cross and Blue Shield of Oklahoma members; affects pharmacies, prescribers, and members enrolled in BCBSOK plans. Some limits may vary by plan or state and some drugs may be excluded from certain channels (e.g., mail).

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPerformance Dispensing Limits (DL)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionIf a prescriber writes a quantity greater than the dispensing limit, the member may still obtain the medication but is responsible for cost beyond coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 DAYScommon dispensing period referenced for many products

28 DAYSalternate dispensing period used for some injectables

common limit = 2many biologic injectables limited to 2 units per 28 days

Quantity limits listedexamples include tablets, mLs, syringes, pens, inhalers, vials

100 g/30

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cumulative topical gram limits noted

Dispensing Limits and Coverage Criteria

Dispensing limit criteria

Dispensing limits are applied to listed brand drugs and their generics where available. Limits may not apply to all members and may be subject to plan or state-specific variations.

Dispensing limits apply to the listed brand drugs and their generic equivalents where available.

Limits are specified as maximum quantities allowed per defined time periods (e.g., Per 28 DAYS, Per 30 DAYS, Per 90 DAYS).

Some dispensing limits are cumulative across multiple formulations or agents within the same drug class (e.g., topical corticosteroids, oral triptans).

Certain dispensing limits or exclusions may vary by member plan or state regulation; check plan materials or the member ID card for applicable variations.

If a prescriber writes a quantity greater than the dispensing limit, the member may still obtain the medication but is responsible for the full cost of the prescription beyond what coverage allows.

Some drug categories (for example, specialty medications) may be limited to shorter supplies (commonly 30-day supplies) or may be excluded from certain channels (for example, mail service) depending on the benefit plan.

per-product dispensing rules

Per-product dispensing limits and formulary indicators

Each product listing specifies a dispensing limit (quantity per time period) and a brand/generic applicability indicator (B = Brand only, G = Generic only, BG = Brand and Generic).

Examples

Adalimumab (multiple biosimilars and formulations): 2 syringes or 2 pens per 28 DAYS (brand/designation varies by listing).
Albuterol inhalers: 2 Inhalers Per 30 DAYS (BG).
Albuterol nebulizer solution: often listed as 120 Vials Per 30 DAYS or equivalent mL limits depending on concentration.
Almotriptan and other oral triptans: cumulative maximum 18 Tablets Per 30 DAYS across all oral triptans/triptan combinations.

Sample dispensing limit criteria

Per-drug dispensing limit entries (examples):

Sample entries

Amphetamine sulfate tab 10 mg (Evekeo): 180 Tablets Per 30 DAYS (B/BG per listing).
Amphetamine extended-release formulations (examples: Dyanavel Xr): commonly 30 Tablets Per 30 DAYS depending on strength.
Apixaban tab 5 mg (Eliquis): 74 Tablets Per 30 DAYS (B).

Each example entry pairs a specific product/strength with a defined numeric limit and brand/generic designation as shown in the product table entries.

Injectable/vial limits

Injectable and specialty product examples:

ANY of the following

Anakinra 100 mg/0.67 mL prefilled syringe (Kineret): 28 Syringes Per 28 DAYS (B).
High-cost coagulation and C1 esterase inhibitors (examples: antihemophilic factors, Cinryze, Berinert, Haegarda): limits expressed in mL or vials per period (e.g., many entries show 1 mL Per 30 DAYS for factor products; Cinryze: 20 Vials Per 30 DAYS with calculation note).

Some injectable limits include calculation notes explaining derivation (for example, Cinryze IU-based vial calculation).

Product dispensing rules

Product-level dispensing rules (examples from excerpt):

ANY of the following

Asenapine transdermal patch (Secuado) 5.7 mg/24 hr: 30 Patches Per 30 DAYS (B).
Atazanavir oral powder packet 50 mg (Reyataz): 240 Packets Per 30 DAYS (B).
Azithromycin 250 mg (Zithromax Z-Pak): 60 Tablets Per 180 DAYS; quantity limits cumulative across strengths (BG).
Aztreonam lysine for inhalation (Cayston): 1 Kit Per 56 DAYS (B).
Baloxavir marboxil therapy pack (Xofluza): 2 Tablets Per 120 DAYS (B).

Dispensing limits table (excerpt)

Dispensing quantity limits and brand/generic applicability for specified products.

ANY of the following

Budesonide oral suspension (Eohilia): 1800 mLs Per 90 DAYS (BG).
Symbicort (budesonide-formoterol) 160-4.5 mcg/act: 3 Inhalers Per 30 DAYS (BG).
C1 esterase inhibitor products (Cinryze, Berinert, Haegarda): vial limits per 28-30 day windows (examples: Cinryze 20 Vials Per 30 DAYS; Haegarda 27 vials per 28 DAYS for 2000u).
Clobetasol topical family: cumulative limits such as 100 Grams Per 30 DAYS or 180 Grams Per 90 DAYS applied across agents (B/G depending on product).
Cladribine (Mavenclad) therapy packs: specified tablet counts per 301 DAYS (various pack sizes listed).

Example dispensing rules

Selected examples from the listed dispensing limits:

ANY of the following

Cladribine tab therapy pack 10 mg (8 tabs) (Mavenclad): 8 Tablets Per 301 DAYS (B).
Clarithromycin ER 500 mg: 28 Tablets Per 180 DAYS (G).
Clobetasol propionate cream 0.025%: 100 Grams Per 30 DAYS; noted as 100/30 cumulative across agents (B).
Clobetasol propionate cream 0.05%: 180 Grams Per 90 DAYS; 180/90 cumulative across agents (G).

These examples illustrate both fixed per-period limits and cumulative limits applied across related agents where specified.

Injectable biologic limits

Injectable coagulation factors and similar biologics have low per-period volume limits:

ANY of the following

Coagulation factor IX (recombinant) products (example: Ixinity, Rixubis, Benefix): Dispensing Limit = 1 mL Per 30 DAYS for listed vial sizes.
Coagulation factor VIIa (Sevenfact) and related factor kits: Dispensing Limit = 1 mL Per 30 DAYS as listed.

Multiple recombinant coagulation factor entries are listed with the same low per-period mL/vial limit, reflecting per-period volume caps for these biologics.

CGM supplies limits

Continuous glucose monitoring supplies limits:

ANY of the following

Dexcom G6/G7 sensors and similar CGM sensors: typically 2-3 Sensors Per 28-30 DAYS depending on model.
Continuous glucose system receiver (Dexcom, Freestyle models): Dispensing Limit = 1 Receiver Per 365 DAYS.
Dexcom G6 transmitter: Dispensing Limit = 1 Transmitter Per 90 DAYS.

CGM supplies listings specify sensors, receivers, and transmitters with distinct per-period limits appropriate to each device type.

Sample coverage lines

Per-product dispensing limits and coverage status:

ANY of the following

Dasatinib tab 20 mg (Phyrago): 90 Tablets Per 30 DAYS; status code BG.
Decitabine-cedazuridine tab (Inqovi): 5 Tablets Per 28 DAYS; status code B.
Deferasirox granules packet (Jadenu Sprinkle): 180 Packets Per 30 DAYS; status code BG.

Each sample coverage line shows the product, the numeric dispensing limit and the brand/generic coverage code used in the list.

drug_dispensing_limits_list

Per-drug dispensing limits (quantity per time period) and brand/generic applicability where listed.

ANY of the following

Diphenoxylate with atropine liquid 2.5/0.025 mg/5 mL: 1200 mLs Per 30 DAYS (B).
Diroximel fumarate (Vumerity) 231 mg: 120 Capsules Per 30 DAYS (B).
Dolutegravir 10 mg (Tivicay) oral tabs: 240 Tablets Per 30 DAYS (B); various dolutegravir formulations have product-specific limits (examples show 60, 360 tablets per 30 days for other forms).

Product-specific dispensing rules (sample)

Per-product dispensing limits and brand/generic status

ANY of the following

Empagliflozin‑metformin formulations (Synjardy family): commonly 60 Tablets Per 30 DAYS (B).
Emtricitabine capsules 200 mg (Emtriva): 30 Capsules Per 30 DAYS (BG).
Emtricitabine‑tenofovir combinations (Descovy/Truvada examples): typically 30 Tablets Per 30 DAYS with brand/generic designation per listing.

Product-specific entries specify both the numeric limit and the BG/B/G designation for the listed formulations.

Injectable GLP-1 fill restriction

Special fill restrictions

Injectable GLP-1 agents (examples include exenatide, dulaglutide, liraglutide, Bydureon Bcise): fill limit of one injectable GLP-1 agent and one strength per 28 days; refill window applies where noted.

Some GLP-1 and other injectable products also have pen/ device-based quantity limits per 28 or 30 day periods (e.g., 3 Pens Per 30 DAYS for certain products).

Dispensing limits and product status

Drug-specific dispensing limits and brand/generic availability rules apply as listed below for each product.

The document lists product-by-product dispensing limits and indicates brand/generic applicability; follow the specific line entry for the product and strength to determine the exact limit and designation.

Some classes have cumulative caps across formulations or agents (for example, oral triptans have a cumulative cap of 18 tablets per 30 days).

Product dispensing rules (sample entries)

Per-product dispensing limits (quantity and time window) and brand/generic designation.

ANY of the following

Gabapentin (Gralise) 600 mg: 90 Tablets Per 30 DAYS (BG).
Galcanezumab (Emgality) injection devices: 1 Injection Device Per 28 DAYS (B) or other device-based limits depending on formulation.
Glucose blood test strips (example: D‑Care): 204 Strips Per 30 DAYS (B).

Each product listing provides the numeric limit and the brand/generic designation to be applied at dispensing.

Per-product dispensing limits

Dispensing limits apply per product and in some cases are cumulative across formulations of the same drug class.

Many insulin and injectable formulations have a common per-product limit such as 100 mLs Per 30 DAYS; where specified, quantity limits may be cumulative across injectable formulations of the same active ingredient. Examples include insulin aspart and insulin glargine family entries.

Some products are listed as kits with longer replacement intervals (for example, pump introductory kits) while consumable components (pods/reservoirs) have monthly limits.

Pump and consumable limits

Durable medical equipment and pump supplies have longer replacement intervals or monthly pod limits.

ANY of the following

Insulin infusion pump intro kits (Omnipod, Ilet): 1 Kit Per 720 DAYS (replacement devices limited to long intervals).
Omnipod/other pump reservoirs/pods: commonly 30 Pods Per 30 DAYS for consumable refill items.
Some pump supply SKUs list multiple kit limits per 30 days depending on the specific supply type.

These device/supply rules distinguish between one-time device replacement intervals and recurring consumable refill limits.

Dispensing limit entries

Product-specific per-30-day dispensing limits (as listed):

ANY of the following

Insulin lispro (Lyumjev) formulations and pens: 100 mLs Per 30 DAYS.
Insulin pen needles and insulin syringes: 300 units (needles or syringes) Per 30 DAYS; quantity limits are cumulative across all pen needles or across all insulin syringes as specified.
Afrezza cartridges (various cartridge sizes): dispensing limits vary by cartridge size with large numeric caps per 30 DAYS (examples listed per cartridge configuration).

These entries emphasize cumulative quantity rules for consumables (pen needles/syringes) and consistent per-period caps for liquid insulin products.

Product dispensing limits

Per-product dispensing limits and brand/generic designation

ANY of the following

Insulin syringes (multiple brands/sizes): 300 Syringes Per 30 DAYS; QL cumulative across insulin syringes.
Rebif Rebidose Titration Pack (interferon beta) kit: 1 Kit Per 180 DAYS (titration pack composition noted).
Rebif prefilled syringes (22/44 mcg): 12 Syringes Per 28 DAYS; QL cumulative across strengths.
Ipratropium-albuterol nebulizer solution: 540 mLs Per 30 DAYS.
Ivacaftor (Kalydeco) formulations: commonly 60 Tablets/Packets Per 30 DAYS.

Drug-specific dispensing limits

Per-product dispensing limits and formulary status

ANY of the following

Lebrikizumab (Ebglyss) 250 mg/2 mL auto‑inject: 1 Pen Per 28 DAYS (listing shows designation per product).
Ledipasvir‑sofosbuvir (Harvoni) formulations: 28 Packs/Tablets Per 28 DAYS (B).
Liraglutide (Victoza) pen injector: 3 Pens Per 30 DAYS; GLP‑1 fill limit rules apply (one injectable GLP‑1 agent and one strength per 28 days).
Lidocaine topical/patch/gel/cream/powder/solution products: commonly 120 Each Per 30 DAYS with quantity limit cumulative across formulations.

Coding / Code Tables and Key Facts

Prescriber and Pharmacy Actions / Alerts

Note

Over-limit prescriptions and member financial responsibility

If a prescription exceeds the plan's dispensing limit, members may pay out-of-pocket for the amount above the limit. Dispensing limits may apply per product, per strength, per device (pens/syringes/pods/vials), and can be cumulative across agents or formulations within a therapeutic class.

Member financial responsibility applies for quantities beyond the listed dispensing limit.
Some limits apply cumulatively across agents (e.g., oral triptans maximum 18 tablets/30 days; topical clobetasol 100 g/30 days or 180 g/90 days cumulative).
Verify member-specific plan exclusions, state variations, and mail-service availability via plan materials or member ID.

Billing Rule

Dispensing limits (quantity limits) and brand/generic flags

Many biologics and injectables are limited by units (syringes/pens) or volume (mLs or vials) per period. Examples below show per-device/per-vial limits and the BG/B/G designations that indicate whether the limit applies to brand, generic, or both.

Definitions and Term Clarifications

Dispensing limit (definition and common attributes)

Dispensing limit definitionMaximum quantity of covered medication that may be dispensed per prescription or within a specified time period (e.g., Per 30 DAYS)

Examples of unitsUnits can include Tablets, Capsules, mLs, Vials, Pens, Syringes, Inhalers, Patches, Packs/Kits

Brand/Generic applicability codesEntries in the list include BG (Brand & Generic), B (Brand only), or G (Generic only) to indicate applicability

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPerformance Dispensing Limits (DL)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionIf a prescriber writes a quantity greater than the dispensing limit, the member may still obtain the medication but is responsible for cost beyond coverage.

SourceLink

On This Page

Per-product rules may include cumulative language (QL cumulative) when limits apply across strengths or formulations of the same agent class.

Product entries show both the numeric dispensing limit and the product designation (B/BG/G) as applicable.

The table includes many additional products with specified per-period quantity limits and BG/B/G designations as shown in the excerpt.

Ixekizumab (Taltz) prefilled syringe: 1 Syringe Per 28 DAYS.

Ketorolac tromethamine tab 10 mg: 20 Tablets Per 30 DAYS (aligns with product labeling for short-course therapy).

Ledipasvir‑sofosbuvir (Harvoni) formulations: 28 Packs/Tablets Per 28 DAYS.

Lemborexant (Dayvigo): 30 Tablets Per 30 DAYS. Lenacapavir (Yeztugo): 4 Tablets Per 365 DAYS.

Adalimumab biosimilars (multiple presentations) — commonly limited to 2 syringes/pens per 28 days; designation: Brand (B) for listed products.
Anakinra (Kineret) — 28 syringes per 28 days; designation: Brand (B).
Antihemophilic factors (e.g., Xyntha, Nuwiq, Novoeight, Hemofil M) — examples show 1 mL per 30 days for some products; designation: Brand (B).
C1 esterase inhibitor examples (Cinryze, Berinert, Haegarda) — vial limits given in vials per 28–30 days with calculation notes (see dup. block).

Documentation Required

Injectable/vial dispensing limits and calculation notes

Injectable and vial products may be limited by number of vials or milliliters per time window. Quantity calculations are sometimes shown as examples to explain the basis for the limit (weight-based or dosing-interval calculations).

Cinryze (C1 esterase inhibitor 500 IU) — Dispensing Limit = 20 vials per 30 days; example calc: 1,000 IU every 3 days = 10,000 IU/30 days ÷ 500 IU/vial = 20 vials.
Berinert (500 IU vial) — Dispensing Limit = 10 vials per 30 days (example based on CDC 90th percentile weight and expected attacks).
Haegarda (2000 IU or 3000 IU subcutaneous) — Dispensing limits expressed in vials per 28 days (27 vials/28 days for 2000 IU; 18 vials/28 days for 3000 IU) with dosing/weight rationale.

Billing Rule

Dispensing limits and product designations

Product entries list the per-prescription or per-period cap and a designation indicating applicability to Brand, Generic, or both. Providers and pharmacies should use the listed unit (tablets, mLs, syringes, pens, pods, vials, kits) when verifying limits.

Triptans (oral) — cumulative maximum 18 tablets per 30 days across all agents; individual product entries list 18 tablets/30 days.
Topical corticosteroids — several agents have per-product limits and also cumulative caps across formulations (e.g., clobetasol 100 g/30 days or 180 g/90 days cumulative across agents).
Insulins — many insulin products limited to 100 mLs per 30 days; insulin pens/cartridges and reservoirs have specified mL limits.
Insulin syringes — capped at 300 syringes per 30 days cumulative for all insulin syringes.

Documentation Required

Dupilumab dispensing units and mL equivalents

Dupilumab dispensing is expressed in pens or syringes per 28 days with equivalent milliliter conversions provided for planning/coverage purposes.

Dupixent 200 mg/1.14 mL auto-injector — Dispensing Limit = 2 pens per 28 days (2 pens = 2.28 mL).
Dupixent 300 mg/2 mL auto-injector — Dispensing Limit = 4 pens per 28 days.
Dupixent prefilled syringe 100 mg/0.67 mL — Dispensing Limit = 2 syringes per 28 days (2 syringes = 1.34 mL).
Dupixent prefilled syringe 200 mg/1.14 mL — Dispensing Limit = 2 syringes per 28 days (2 syringes = 2.28 mL).
Dupixent prefilled syringe 300 mg/2 mL — Dispensing Limit = 4 syringes per 28 days (1 carton = 2 syringes = 4 mL).

Billing Rule

Dispensing limits per product and GLP-1 fill restrictions

The list includes many per-product dispensing limits expressed in the product's dispensing unit. Providers should confirm the appropriate unit and time window when prescribing.

Dulaglutide (Trulicity) — 4 pens per 28 days; fill limit: one injectable GLP-1 agent and one strength per 28 days (refill window applies).
Dulaglutide available strengths: 0.75 mg, 1.5 mg, 3 mg pens with limits of 4 pens/28 days.
Liraglutide (Victoza) — 3 pens per 30 days; fill limit: one injectable GLP-1 agent and one strength per 28 days.
Exenatide (Bydureon Bcise and Byetta) — typical limits 4 pens/28 days (Bydureon) or 1 pen/30 days (Byetta); refill window applies.

Billing Rule

Cumulative dispensing rules across agents/formulations

Some dispensing limits are cumulative across multiple formulations or agents within a therapeutic class. Pharmacies must enforce cumulative caps when multiple products in the same class are dispensed to the same member within the defined period.

Oral triptans and triptan combinations — cumulative maximum of 18 tablets per 30 days across all agents.
Topical clobetasol formulations — limits expressed as 100 g per 30 days or 180 g per 90 days, cumulative across agents and formulations.
Topical fluocinonide/halcinonide/flurandrenolide examples — cumulative caps (e.g., 100 g/30 days or 180 g/90 days) across agents.
Lidocaine topical formulations — cumulative quantity limits (e.g., 120 units per 30 days) across formulations.

Note

Product dispensing examples and device limits

Examples and special-device limits illustrate product-specific rules and device kit/reservoir constraints.

Zymfentra (infliximab autoinjector) — 2 pens per 28 days for listed pen and syringe kits.
Omnipod insulin infusion disposable pump kits — Dispensing Limit = 1 kit per 720 days; reservoirs/pods limited to 30 pods per 30 days.
Omnipod reservoirs/pods examples list 30 pods per 30 days for multiple Pod generations.
Rebif Rebidose titration pack — Dispensing Limit = 1 kit per 180 days (titration kit composition noted).

Billing Rule

Pump and reservoir dispensing limits

Pump kits and disposable reservoir/pod supplies have separate dispensing limits from drug solutions and are tracked per kit or per pod/reservoir.

Insulin infusion disposable pump kit (Omnipod series) — 1 kit per 720 days.
Omnipod reservoirs/pods — 30 pods per 30 days for supported Pod/Gen combinations.
Pump kit and reservoir limits are separate from insulin mL limits and from pen/cartridge limits; providers should prescribe according to the device-specific rules.

Billing Rule

Dispensing limits and cumulative quantity rules

Specific cumulative quantity rules apply to categories such as insulin syringes and certain topical agents; check cumulative QL when multiple NDCs or presentations are involved.

Insulin syringes — cumulative cap of 300 syringes per 30 days across syringe SKUs.
Topical corticosteroids (clobetasol, halcinonide, etc.) — cumulative gram or mL caps across formulations and products as listed (e.g., clobetasol 100 g/30 days or 180 g/90 days).
Lidocaine topical products — cumulative 120 units per 30 days across formulations.

Step Therapy

GLP-1 injectable and oral fill limits

For GLP-1 class products (injectable and oral), the plan enforces a one-agent/one-strength fill limit within the defined window to prevent concurrent fills of multiple GLP-1 products or strengths.

Fill limit: one injectable GLP-1 agent and one strength per 28 days (refill window applies).
Examples: Dulaglutide (Trulicity) — 4 pens/28 days with the one-agent/one-strength rule; Liraglutide (Victoza) — 3 pens/30 days with the same fill restriction; Exenatide examples show 1 pen/30 days (Byetta) or 4 pens/28 days (Bydureon).
Oral GLP-1s follow a similar one-agent/one-strength per 28 days fill limit where noted.