CurrentIndependent HealthPolicy N/A

Formulary quantity limits (drug-specific QLs)

Independent Health quantity limits for medications on its 2025 formularies; defines per-fill and per-time-period maximum quantities for specific drugs and forms, and rules for pre-packaged items. Affects pharmacies, prescribers, and billing/claims personnel for Independent Health members.

Policy Summary

PayerIndependent Health

PolicyFormulary quantity limits (drug-specific QLs)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date12/1/2025

Next Review DateN/A

Key ActionPharmacies and prescribers must adhere to the specified quantity limits per drug/formulation and per time period when dispensing or submitting claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-12-01document currency date

100+number of listed drugs with quantity limits (approx.)

per-druglimits expressed as EA/ML/fills per time period

Policy Snapshot

This is Independent Health’s formulary Quantity Limits (QL) list for multiple 2025 formularies, effective 12/1/2025. It defines maximum permitted amounts of specific medications per specified time period (for example, per 30 days, per fill, per year) and includes rules for pre-packaged items (one package size allowed per fill unless a formulary QL specifies otherwise). Document type: other.

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Quantity Limit Rule and Scope

This document is a formulary quantity limits index and per-product listing for Independent Health’s 2025 formularies. It lists drug-specific quantity limits (examples include limits expressed as EA, mL, or fills per time period) but does not include numeric billing or procedure codes (CPT/HCPCS) or diagnosis codes (ICD). For prior authorization, coverage criteria, exceptions, or detailed utilization management requirements, consult Independent Health’s other policies or contact Member Services as noted in the formulary.

Key threshold

Per-fill package ruleOne package size allowed per fill for pre-packaged items unless a formulary QL takes precedence

Listed Products and Quantity Limits

Listed products and their quantity limits (examples extracted)mixedCovered

Airsupra	Quantity Limit: listed (see formulary) — entry date 12.1.2025
Akynzeo (oral capsule / inhaler)	Quantity Limit: 1 inhaler per 30 days; AKYNZEO ORAL CAPSULE Quantity Limit: 1 EA max per fill (retail)
Albuterol Sulfate HFA (aerosol)	Quantity Limit: 1 inhaler per 30 days
Almotriptan Malate (oral tablet)	Quantity Limit: 6 EA per 30 days
Amphetamine-Dextroamphetamine (tablets)	Quantity Limit: 3 EA per 1 day
Andembry (auto-injector)	Quantity Limit: 2.4 mL per 30 days
Anzemet (oral tablet 50 mg)	Quantity Limit: 5 EA per 30 days
Aprepitant (capsules)	Quantity Limit: various — e.g., 3 EA per 30 days (125/80 mg); 1 EA per 30 days (40 mg)
Avmapki Fakzynja Co-Pack	Quantity Limit: 66 EA per 28 days
Benzonatate 100 mg	Quantity Limit: 60 EA per 10 days

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Operational note: This document is a formulary quantity limits list current as of 12/1/2025; for prior authorization, coverage criteria, or exception processes consult other Independent Health policies or Member Services.

What Pharmacies, Prescribers, and Billing Staff Must Do

Documentation Required

Follow formulary quantity limits

Pharmacies and prescribers must adhere to the specified quantity limits per drug/formulation and per time period when dispensing or submitting claims. If a formulary-designated quantity limit exists it overrides default one-package-per-fill rules for pre-packaged items.

Billing Rule

Claims may be limited by QL

Claims exceeding the listed quantity limits may be rejected or require prior authorization per standard Independent Health processes; contact Member Services for questions.

Contact Member Services at 1-800-501-3439 or (716) 631-8701, Monday–Friday 8 a.m. to 8 p.m.; TTY users call 711.

Clinical / Administrative Context

Note: the formulary includes a broad index of covered products with their assigned quantity limits (for example, inhalers limited to 1 inhaler per 30 days, or certain injectables limited by mL or number of syringes per period). Pre-packaged items are normally limited to one package per fill unless the formulary QL explicitly overrides that rule; contact Member Services for questions about claims or exceptions.