Determining quantity limits
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This document describes the payer's pharmacy quantity limits program — how quantity limits are determined and specific quantity limits applied to listed medications; it affects members and pharmacies under Hometown Health's pharmacy benefit.
No material clinical or coverage changes in this revision.
Medication-Specific Quantity Limits
medication-specific quantity limits (partial list in this document segment)
The following medication-specific quantity limits apply (examples shown). Each listed medication has an associated numeric limit stated as per fill, per day, per 28/30/84/365 days, or as course/fills per 365 days.
explicit quantity entries
Sample explicit quantity limit entries extracted from this portion of the policy:
Per-product quantity criteria
Quantity limits applied according to product and patient opioid experience:
Quantity limit criteria
Quantity and fill limits for listed opioid products:
Product-specific quantity criteria
Quantity limits apply by product and by patient treatment status (new vs experienced).
Quantity limits by product
Quantity limits applied by product and patient opioid experience:
Premium Non-Specialty Quantity Limits
Quantity limits vary by product and patient opioid experience status.
Premium Non-Specialty quantity limits
Quantity limits applied under Premium Non-Specialty:
document also contains repeated mentions of 20 tabs/day in fragments
Quantity limit criteria (excerpt)
Quantity limits are applied per medication and differ for new versus experienced opioid patients. Examples from the excerpt include:
Quantity limits by medication and patient opioid experience
Quantity limits vary by medication formulation and patient opioid experience status.
Hydromorphone quantity limit criteria
Daily quantity limits by formulation and patient opioid experience:
Hydromorphone quantity limit criteria
Quantity limits apply by medication and patient opioid experience status.
Premium Non-Specialty Quantity Limits (opioids)
Per-product daily quantity limits are set, often with separate limits for opioid-naive (new) versus experienced patients and common short maximum supply durations.
Examples of per-product quantity limits
Medication-specific quantity limits (examples):
Examples of per-product quantity limits
Quantity limits specified by medication and time period; must be followed when dispensing or adjudicating claims.
Code & Product References
| NUZYRA TAB 150 MG | listed medication with quantity limits (1 course per fill, 2 fills per 365 days) |
| SIVEXTRO IV SOLN | listed medication with vial/tablet limits (6 vials per 30 days / 6 tablets per 30 days) |
| ZYVOX SUSP 100 MG/5 ML | listed medication with quantity limits (900 mL per 28 days / 28 tablets per 30 days) |
| celecoxib cap 2 capsules per day |
| diclofenac gel 1% 10 tubes per month | |
| diclofenac patch 2 patches per day up to 15 days |
| Multiple medication names and strengths cited (ketorolac tab, orphenadrine/aspirin/caffeine tab 25-385-30 mg, methylphenidate tab, ONYDA XR suspension, PROCENTRA solution, RELEXXII, NAMENDA XR) |
| Document lists product names (e.g., ACTIQ lozenge, BELBUCA film, buprenorphine patch, butorphanol nasal spray, codeine tabs) but does not provide billing codes in this segment. |
| codeine tab (15 mg, 30 mg, 60 mg), buprenorphine patch, butorphonal nasal spray referenced |
| codeine 15 mg | tablet strength referenced with limits (21 tabs/day new; 40 tabs/day experienced) |
| codeine 30 mg | tablet strength referenced with limits (10 tabs/day new; 20 tabs/day experienced) |
| codeine 60 mg | tablet strength referenced with limits (5 tabs/day new; 10-40 tabs/day experienced depending on fragments) |
| fentanyl patch 75 mcg/hr | 1 patch per day; 15 patches per 30 days |
| fentanyl patch 100 mcg/hr | 1 patch per day; 15 patches per 30 days |
| hydrocodone ER 50 mg | example limit 2 capsules per day |
| fentanyl patch | 15 patches per 30 days; some strengths (75 mcg/hr, 100 mcg/hr) limited to 1 patch per day |
| codeine tab 60 mg | quantity limits described (5/day new; 10/day experienced) |
| fentanyl patch 75 mcg/hr | 1 patch per day; 15 patches per 30 days |
| fentanyl patch 100 mcg/hr | 1 patch per day; 15 patches per 30 days |
| hydrocodone ER cap | 2 capsules per day (general); 50 mg strength referenced as 4 capsules per day |
| Medications listed include fentanyl patch (75 and 100 mcg/hr), hydrocodone ER capsules (including 50 mg), hydrocodone/acetaminophen solutions and tablets, codeine 60 mg, hydrocodone/ibuprofen and hydromorphone formulations (no standardized billing codes shown in this segment). |
| No codes listed |
| No codes listed |
| hydromorphone tab 2 mg, hydromorphone tab 4 mg, hydromorphone supp 3 mg referenced without billing codes in this section |
| Multiple hydromorphone tablet strengths listed (2 mg, 4 mg, 8 mg) with quantity-limit placeholders |
| Oxycodone and oxycodone/acetaminophen formulations with specified per-day limits for new vs experienced patients (examples include oxycodone/acetaminophen 10-325 mg: 3 tabs/day new; 6 tabs/day experienced) |
| Document contains medication names and plain-language quantity limits but does not list standardized billing codes in this section. |
| Medication-level quantity limits (examples: granisetron tab 1 mg = 4 tablets per 30 days; ondansetron soln 4 mg/5 mL = 120 mL per 30 days; MARINOL CAP = 2 capsules per day) |
Key Terms and Timeframes
Prescriber & Pharmacy Guidance
Member/provider notification and appeals path
If your medication is listed with a quantity limit, this notice explains there is a new limit on the amount covered. Members and providers are encouraged to discuss treatment options with the prescriber; questions about the quantity limits program should be directed to the phone number on the member ID card.
HYCODAN tablet — daily quantity and course limit
HYCODAN tablets (5–1.5 mg) are limited to 6 tablets per day with a 7‑day supply; the entry also pairs this with 2 fills per 60 days for the syrup formulation in the same product group.
- 6 tabs per day; 7 day supply
- Syrup: 240 mL per fill, 2 fills per 60 days (related entry)
MAR‑COF CG liquid — per‑fill volume and refill frequency
MAR‑COF CG liquid (225–7.5 mg/5 mL) is limited to 240 mL per fill and is eligible for 2 fills per 60 days.
- 240 mL per fill
- 2 fills per 60 days
Ketorolac — quantity per 30 days
Ketorolac tablets are limited to 20 tablets (equivalent to a 5‑day supply) per 30 days.
- 20 tablets or 5‑day supply per 30 days
QUTENZA patch kit — periodic patch limit
QUTENZA patch kits are limited to 4 patches per 90 days.
- 4 patches per 90 days
Quantity limits — miscellaneous non‑specialty meds
A range of non‑specialty medications have specific quantity limits listed (examples include ketorolac, orphenadrine combinations, methylphenidate products, RELEXXII, NAMENDA XR, and QUTENZA); providers must follow the per‑drug limits shown when dispensing.
- Examples: ketorolac tab 20 tabs/30 days; orphenadrine/aspirin/caffeine tab 4 tabs/day; methylphenidate tabs 3 tabs/day
- Follow the specific per‑drug time period shown (per day / per 28/30/90/365 days)
Opioid liquid — new vs experienced patient volume limits
Opioid analgesic liquid (acetaminophen/codeine 120–12 mg/5 mL) is limited to 136 mL/day for patients new to opioid treatment and 166.5 mL/day for experienced opioid patients; new‑patient liquid limits often apply for up to 7 days.
- New to opioid treatment: 136 mL/day (often up to 7 days)
- Experienced with opioid treatment: 166.5 mL/day
Opioid tablet quantity rules (by strength and experience)
Tablet limits for acetaminophen/codeine and similar opioid tablets vary by strength and opioid experience; examples include new‑patient limits of 5–13 tabs/day (for up to 7 days) with higher experienced‑patient limits depending on the agent.
- New patients: examples shown of 5–13 tabs/day for up to 7 days (varies by strength)
- Experienced patients: higher per‑day limits (examples vary by agent)
Special products — lozenges, films, patches, nasal sprays
Certain special products have specific per‑day or per‑fill limits: ACTIQ lozenges 4 lozenges/day; BELBUCA films 2 films/day; buprenorphine patch 4 patches per 28 days; select nasal sprays limited to 1 bottle per fill with 2 fills per 60 days.
- ACTIQ: 4 lozenges per day
- BELBUCA: 2 films per day
- Buprenorphine patch: 4 patches per 28 days
- Butorphanol nasal spray: 1 bottle per fill, 2 fills per 60 days
Quantity limits — summary for opioid products
Quantity limits and fill frequencies are specified per opioid product and differ for patients new to opioid treatment versus experienced patients; prescribers and pharmacies must apply the appropriate per‑product limits.
- Limits differ by patient opioid experience (new vs experienced)
- Follow listed per‑drug daily or per‑period limits when adjudicating claims
Quantity limits by treatment status (new vs experienced)
The program differentiates quantity limits by treatment status: patients new to opioid treatment generally receive lower daily tablet or volume limits (commonly limited to short courses up to 7 days), while experienced patients are eligible for higher per‑day limits.
- New to opioid treatment: lower short‑term daily limits, often for up to 7 days
- Experienced patients: higher daily limits as specified per product
Quantity limits by opioid experience (tablets)
Prescriptions for opioid tablets are limited based on patient opioid experience. Examples include new‑patient limits (e.g., 21 tabs/day for some strengths; codeine 30 mg limited to 10 tabs/day; codeine 60 mg limited to 5 tabs/day for up to 7 days) and higher experienced‑patient limits (examples: 20–40 tabs/day depending on strength).
- Codeine 15 mg: new 21 tabs/day (up to 7 days) — experienced 40 tabs/day
- Codeine 30 mg: new 10 tabs/day (up to 7 days) — experienced 20 tabs/day
- Codeine 60 mg: new 5 tabs/day (up to 7 days) — experienced higher limits noted in document
Fentanyl patch — per‑day and monthly limits
Fentanyl patches are limited to 15 patches per 30 days; specific strengths (75 mcg/hr and 100 mcg/hr) are further constrained to 1 patch per day.
- Maximum 15 patches per 30 days
- 75 mcg/hr and 100 mcg/hr: 1 patch per day
Hydrocodone ER — example daily capsule limit
Hydrocodone ER capsules are referenced with an example limit of 2 capsules per day (with a 50 mg strength elsewhere noted as up to 4 capsules/day in other fragments); providers should apply the per‑product limit shown in the list.
- Hydrocodone ER cap: commonly listed as 2 capsules per day
- Hydrocodone ER 50 mg: some entries reference 4 capsules per day (document contains both entries)
Prior authorization / quantity restriction — oral opioid tablets
Oral opioid tablet prescriptions are subject to quantity restrictions based on patient opioid experience: new patients receive lower daily tablet limits (examples: 5 or 10 tabs/day for up to 7 days) while experienced users receive higher limits (examples: 10 or 20 tabs/day); these restrictions function as quantity‑based prior authorization/coverage criteria.
- New to opioid treatment: lower daily limits (e.g., 5 or 10 tabs/day) often for up to 7 days
- Experienced: higher per‑day limits (examples vary by product)
Quantity limits — consolidated summary
Quantity limits are specified per product and adjusted for patient opioid experience; examples include codeine (5 tabs/day new, 10 tabs/day experienced), fentanyl patches (15/30 days), and hydrocodone solution limits for new patients (98 mL/day).
- Codeine 60 mg: new 5 tabs/day (up to 7 days); experienced 10 tabs/day
- Fentanyl patch: 15 patches per 30 days
- Hydrocodone/acetaminophen soln (7.5–325 mg/15 mL): new 98 mL/day (up to 7 days)
Codeine 60 mg — new vs experienced patient limits
Codeine 60 mg prescriptions are limited for patients new to opioid treatment to 5 tablets per day for up to 7 days; experienced opioid patients are limited to 10 tablets per day.
- New to opioid treatment: 5 tabs/day for up to 7 days
- Experienced with opioid treatment: 10 tabs/day
Fentanyl patch — strength‑specific and monthly caps
Fentanyl patches are capped at 15 patches per 30 days overall; fentanyl 75 mcg/hr and 100 mcg/hr strengths are limited to 1 patch per day.
- 15 patches per 30 days
- 75 mcg/hr and 100 mcg/hr: 1 patch per day
Hydrocodone ER capsule — daily capsule limit (example)
Hydrocodone ER capsules are noted with a general limit of 2 capsules per day; some entries for the 50 mg strength reference 4 capsules per day — follow the specific per‑product entry applicable at claim adjudication.
- General listing: 2 capsules per day
- 50 mg strength: some entries reference 4 capsules per day
Hydrocodone/acetaminophen solution — new‑patient volume limit
Hydrocodone/acetaminophen solution 7.5–325 mg/15 mL for patients new to opioid treatment is limited to 98 mL per day for up to 7 days; experienced patient limits are referenced elsewhere in the document.
- New to opioid treatment: 98 mL/day for up to 7 days
Quantity‑limit prescribing distinctions (Premium Non‑Specialty)
Prescriptions are subject to Premium Non‑Specialty quantity limits that explicitly differentiate between patients new to opioid treatment and those experienced; initial prescriptions are commonly limited to short courses (up to 7 days).
- New vs experienced patient status determines applicable per‑day limits
- Initial prescriptions often limited to up to 7 days
Hydromorphone — formulation‑specific quantity limits
Hydromorphone formulations have specific daily limits by formulation and patient experience: hydromorphone 4 mg tablets — 2 tabs/day for new patients; 2 mg tablets — 5 tabs/day (new, up to 7 days) or 9 tabs/day (experienced); suppositories 3 mg — 3 supps/day (new) or 6 supps/day (experienced); liquid — 18 mL/day.
- Hydromorphone tab 4 mg: new = 2 tabs/day
- Hydromorphone tab 2 mg: new = 5 tabs/day (up to 7 days); experienced = 9 tabs/day
- Hydromorphone supp 3 mg: new = 3 supps/day (up to 7 days); experienced = 6 supps/day
- Hydromorphone liquid: limit 18 mL/day
Hydromorphone — limits by opioid experience
Daily quantity limits are applied by opioid experience status for hydromorphone and similar agents; examples include hydromorphone supp 3 mg limited to 3 supps/day (new) or 6 supps/day (experienced) and hydromorphone tab 2 mg limited to 5 tabs/day (new) or 9 tabs/day (experienced).
- Hydromorphone supp 3 mg: new 3 supps/day; experienced 6 supps/day
- Hydromorphone tab 2 mg: new 5 tabs/day; experienced 9 tabs/day
Opioid‑naive vs experienced patient quantity limits — program rule
Across the opioid product listings, opioid‑naive (new to treatment) patients are commonly limited to short durations (up to 7 days) with lower daily tab/volume caps, while experienced patients are permitted higher daily limits as specified per product.
- New (opioid‑naive): short courses (commonly up to 7 days) with lower daily limits
- Experienced: higher per‑day limits per product listing
Opioid quantity differentiation by experience
The policy consistently differentiates opioid quantities based on patient experience (new vs experienced), applying short‑term caps (e.g., up to 7 days) and lower per‑day limits for new patients.
- New patients: lower short‑term daily caps (examples shown throughout)
- Experienced patients: higher daily caps where listed
Starter pack — per‑year limits
Certain products are limited by starter‑pack rules expressed as a maximum number of starter packs per 365 days; providers should check the listed starter‑pack limits when dispensing starter kits.
- Example: FETZIMA TITRATION PACK — 2 starter packs per 365 days
- Multiple antipsychotic starter/titration packs listed with 2 starter packs per year
Topical/dermatology — gram/bottle limits
Topical and dermatology products have gram or bottle quantity limits specified per 28/30 days (examples: ENSTILAR FOAM 420 gm per 28 days; calcipotriene/betamethasone ointment 400 gm per 30 days).
- ENSTILAR FOAM: 420 gm per 28 days
- Calcipotriene/betamethasone ointment: 400 gm per 30 days
Per‑medication quantity listings — adherence required
The document lists many per‑drug quantity limits by time period (examples: granisetron tab 1 mg = 2 packs per 30 days; ondansetron solution 4 mg/5 mL = 120 mL per 30 days); pharmacies must adhere to the stated limit for each medication.
- Granisetron tab 1 mg: 2 packs per 30 days
- Ondansetron soln 4 mg/5 mL: 120 mL per 30 days
Tiered limit structure — Non‑Specialty vs Specialty
The quantity limits program uses a tiered structure separating Premium Non‑Specialty and Premium Specialty quantity limits; different agents may have different limits depending on the tier (examples: JUXTAPID vs TRYNGOLZA).
- Premium Non‑Specialty vs Premium Specialty applied to different agents
- Check the applicable tier to determine the correct quantity limit for a product
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