CurrentColorado Rocky Mountain Health PlansPolicy N/A

Drug quantity (supply) limits list

This document lists medications that have duration-based quantity (supply) limits and indicates the maximum quantity covered in a specified timeframe; it applies to Colorado Rocky Mountain Health Plans' pharmacy benefit listings and affects plan adjudication and claims for covered drugs.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyDrug quantity (supply) limits list

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionApply the listed supply limits when adjudicating pharmacy claims and note that inclusion does not guarantee coverage; other plan requirements may apply.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

dozens+drugs listed with quantity limits in this part

Comprehensivemedications with duration quantity limits

180 MEDopioid cumulative dose rule

Yes/NoOverrides flag present

5/1/2026document effective date

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.

Quantity (Supply) Limits — Coverage Criteria

General coverage note

Inclusion and applicability statement for the supply-limits list:

Supply Limits establish the maximum quantity of drug that is covered in a copay or a specified timeframe.

Inclusion in this list does not indicate a drug is covered by a particular plan.

Any drug on the list may be subject to other requirements including but not limited to Exclude at Launch or Review at Launch.

Quantity limit entries

Per-product quantity limit entries include these data elements:

Each drug entry specifies product name, strength/form, and a quantity limit expressed per a timeframe (e.g., per month, per year, or per X days).

Entries commonly include an 'Overrides' flag (Yes/No) indicating whether the listed limit may be overridden under applicable plan rules.

Some entries include supply equivalence mappings (e.g., '62 capsules = 31 tablets' or '1 = 1 transmitter kit/1 year').

Coverage stance and data entries

Stance, scope, and structure of data presented in this section:

The list is a comprehensive compilation of medications that have duration quantity limits; limits are listed per product and strength/form.

Inclusion in the supply limits list does not guarantee coverage; products may be subject to additional plan-specific requirements such as Exclude at Launch or Review at Launch.

Many rows provide primary and secondary fields: a supply-limit quantity (labelled '1') and an applicability flag or alternate value (labelled '2').

Sample per-product supply limit nodes

Examples of per-product supply limits and how they are represented (excerpted):

Kisqali - 200 mg (600 mg daily dose blister pack): 31 tablets = 63 tablets (Overrides = No).

Leqembi LQLIK - 360 mg: 1 = 4 autoinjectors per month (Overrides = No).

Lenvima - 8 mg: 1 = 60 capsules (Overrides = Yes).

Mavyret: 168 tablets per 720 days (sample long-term limit).

Mavenclad - 10 mg: 40 tablets per 720 days (sample long-term limit).

Opioids (long-acting): supply limits are tied to an opioid cumulative dose calculation (Opioid Cumulative Dose = 180 MED).

Coverage stance and criteria

Policy-level statements and operational criteria that apply across listed entries:

Inclusion in this list does not indicate coverage by a particular plan; entries are informational for supply-limit purposes.

Any listed drug may be subject to additional requirements (e.g., Exclude at Launch or Review at Launch) beyond the supply limit itself.

Some entries present both a primary supply limit (label '1') and an alternate/applicability field (label '2') which may be 'Yes', 'No', or an alternate quantity.

Fills sequencing rules (examples)

Certain products require two one-month fills before permitting a three-month fill when a longer fill is allowed (e.g., Rybelsus, Victoza).

Sample coverage criteria entries extracted from supply-limit list

Representative per-entry coverage criteria and special notes (examples):

Victoza (6 mg) — 2-pen pack: two one-month fills are required before a three-month fill is available if allowed (Overrides = Yes for 2-pen pack; 3-pen pack requires trial of 2-pen pack and Overrides = No).

Voquezna - 10 mg: 31 tablets (example of an explicit per-year/course limit).

Wegovy and similar pen-pack products: quantity mappings and sequencing requirements noted; some products require initial shorter fills before longer refills are permitted.

Xarelto Starter Pack: example shows a starter pack limit (e.g., 31 capsules = 1 pack/year).

Zepatier: example long-term limit shown as 30 packets = 84 tablets per 720 days.

Coding & Supply-Entry Structure

inv-12: example timeframe thresholds

example timeframe thresholds

inv-13: Examples of supply thresholds

Examples of supply thresholds

inv-14: long-term therapy tablet caps per timeframe

long-term therapy tablet caps per timeframe

inv-15: opioid cumulative MED threshold

opioid cumulative MED threshold

Provider Impact & Operational Caveats

Note

Quantity limits and additional requirements

Lists medications with a maximum quantity covered in a copay or specified timeframe; inclusion does not guarantee coverage and drugs may be subject to other requirements such as Exclude at Launch or Review at Launch.

Note

Supply limits statement and caveats

Supply Limits establish the maximum quantity of drug that is covered in a copay or a specified timeframe. Inclusion in this list does not indicate a drug is covered by a particular plan; drugs may be subject to other requirements including but not limited to Exclude at Launch or Review at Launch.

Note

Supply limits and plan applicability

The list establishes Supply Limits that set the maximum quantity of drug covered in a copay or specified timeframe; inclusion does not guarantee coverage and drugs may be subject to other requirements (e.g., Exclude at Launch or Review at Launch).

Definitions & Glossary

inv-25: Supply Limits

Definition - Supply LimitsSupply Limits = the maximum quantity of drug that is covered in a copay or a specified timeframe.

Inclusion caveatInclusion in this list does not indicate a drug is covered by a particular plan; additional requirements (e.g., Exclude at Launch or Review at Launch) may apply.

Effective dateEffective 5/1/2026 (Last updated 4/22/2026)

inv-26: Overrides

Overrides field meaningOverrides = an entry field indicating whether the listed quantity limit can be overridden (Yes/No) under applicable plan rules.

PresentationMost entries include a primary value (1) and a secondary Overrides flag (2) showing Yes/No or alternate limits.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyDrug quantity (supply) limits list

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionApply the listed supply limits when adjudicating pharmacy claims and note that inclusion does not guarantee coverage; other plan requirements may apply.

SourceLink

On This Page

Orencia/Orencia Clickjet - 125 mg: quantity mapping shows 4 syringes/autoinjectors = 4 syringes or autoinjectors.

Ozempic - 2 mg/3 mL: quantity mapping shows 4 syringes/autoinjectors = 1 pen.

Palforzia Maintenance (300 mg): 1 pack (30 capsules)/13 days (example of course-based limit).

inv-16: Rybelsus prior fill requirement

Rybelsus prior fill requirement

inv-17: Victoza prior fill requirement

Victoza prior fill requirement

inv-18: Examples of per-period supply thresholds

Examples of per-period supply thresholds

Billing Rule

Opioid cumulative dose rule (180 MED)

Opioid supplies (both long-acting and short-acting) are limited based on a cumulative opioid dose threshold of 180 MED.

Opioids, long acting — Opioid Cumulative Dose: 180 MED
Opioids, short acting — Opioid Cumulative Dose: 180 MED

Documentation Required

Supply limit inclusion and additional requirements

Inclusion in this supply-limits list does not indicate a drug is covered by a particular plan. Any drug may be subject to other requirements including but not limited to Exclude at Launch and/or Review at Launch.

Note

Supply limit advisory

The list provides supply limits (maximum quantity covered in a copay or timeframe) for specific drugs; inclusion does not guarantee coverage and drugs may be subject to other requirements such as Exclude at Launch or Review at Launch.

Applicability noteOverride allowances remain subject to applicable plan rules and do not guarantee coverage changes.

inv-27: Supply Limits (alternate location)

Alternate location noteSupply Limits statements and examples are repeated across the document; see multiple chunks for per-product entries and definitions.

Cross-referenceEntries in chunks 18-38 and 72-80 both show product supply mappings and Overrides flags.

Document scopeComprehensive list applies to duration quantity limits for many products (dozens+ entries).

inv-28: Inclusion caveat

Inclusion does not equal coverageInclusion in this list does not indicate a drug is covered by a particular plan; drugs may be subject to other requirements.

Possible additional requirementsExamples of additional requirements include Exclude at Launch and Review at Launch.

Provider action implicationProviders should verify plan coverage and other utilization management requirements before prescribing beyond listed limits.

inv-29: maximum quantity of drug covered in a copay or a specified timeframe

Maximum quantity definitionMaximum quantity of drug covered in a copay or a specified timeframe (Supply Limits).

Examples of unitsUnits include tablets, capsules, pens, syringes, mL, packets, starter kits, and courses of therapy.

Limit enforcementSupply Limits are used during adjudication to limit quantities covered per copay or timeframe.

inv-30: morphine equivalent dose used to calculate cumulative opioid limits

MED definitionMED = morphine equivalent dose used to calculate cumulative opioid limits.

Opioid ruleOpioid cumulative dose limit applied: 180 MED for both long-acting and short-acting opioids.

List applicationEntries for opioids include the MED-based cumulative rule and an Overrides flag indicating application.

inv-31: Supply Limits (repeated)

Supply limits repeatedSupply Limits definition and many per-product entries are reiterated throughout the document (see header and multiple chunks).

ConsistencyPrimary/secondary (1/2) entry structure is consistently used across sections.

Documentation timestampLast updated 4/22/2026 (For 5/1/2026 Effective Date)

inv-32: Duration quantity limit

Duration quantity limit definitionDuration quantity limit = maximum quantity of drug covered in a copay or specified timeframe (e.g., per 30/31 days, per course/year).

Common monthly value31 tablets per 30/31-day period is a common presentation for monthly limits.

Starter/annual examplesStarter kits and annual starter pack limits are explicitly listed (e.g., starter kits per year).

inv-33: Supply Limits (additional)

Additional supply-limit examplesEntries include multi-pack and packet mappings such as 56 tablets = 2 pens or 56 tablets = 124 packets depending on product.

Pack-to-dose mappingsExamples show 56 tablets mapping to various packet/syringe volumes for different products.

Alternate flag useSome entries list 'No' for the secondary field indicating the alternate limit is not applicable.

inv-34: Duration quantity limit (alternate)

Alternate duration example31 capsules = 1 pack/year (Xarelto Starter Pack) and 30 packets = 84 tablets per 720 days (Zepatier example).

Packet-to-capsule mappings30 packets = 124 packets or 30 packets = 84 tablets style mappings appear for specialty agents.

Frequency unitsLimits may be expressed per days, 365 days (year), or multi-year intervals (e.g., 720 days).