CurrentIndependent HealthPolicy N/A

Quantity Limits — Medicare Advantage Part D Formularies

Defines quantity limits for specific drugs on Independent Health's 2026 Medicare Advantage Part D formularies and describes how members/providers can request exceptions; applies to Medicare Advantage Part D members covered by these formularies.

Policy Summary

PayerIndependent Health

PolicyQuantity Limits — Medicare Advantage Part D Formularies

Policy CodePolicy N/A

Change TypeNo material change

Effective Date6/1/2026

Next Review DateN/A

Key ActionIf a greater quantity than specified is required, the member, designated representative, or provider can request a coverage determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026formulary year

90 EA/30dexample max qty

1-800-665-1502member contact

~17named products shown

Formulary Quantity Limits

Drug-specific quantity limits

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Adempas (oral tablet 0.5 mg, 1 mg, 1.5 mg) — Quantity Limit: 90 EA Per 30 Days

Austedo XR (oral tablet extended release 24 hour 6 mg) — Quantity Limit: 90 EA Per 30 Days

Budesonide (inhalation suspension 0.25 mg/2 mL, 0.5 mg/2 mL, 1 mg/2 mL) — Quantity Limit: 120 ML Per 30 Days

Darifenacin Hydrobromide ER (oral tablet extended release 24 hour 15 mg, 7.5 mg) — Quantity Limit: 30 EA Per 30 Days

Drizalma Sprinkle (oral capsule delayed release sprinkle 20 mg, 30 mg, 40 mg) — Quantity Limit: 8 EA Per 28 Days

Eslicarbazepine Acetate (oral tablet 200 mg, 400 mg) — Quantity Limit: 90 EA Per 30 Days

Fanapt Titration Pack B (oral tablet 1 & 2 & 6 & 8 mg) — Quantity Limit: 12 EA Per 4 Days

Fluticasone Propionate HFA (inhalation aerosol 44 mcg/act) — Quantity Limit: 10.6 GM Per 30 Days

Jardiance (oral tablet 10 mg) — Quantity Limit: 30 EA Per 30 Days

Lytgobi (20 mg daily dose therapy pack) — Quantity Limit: 112 EA Per 28 Days

Neupro (transdermal patch 24 hour 1 mg/24 hr, 2 mg/24 hr, etc.) — Quantity Limit: 30 EA Per 30 Days

Omnipod DASH Pods (Gen 4) — Quantity Limit: 15 EA Per 30 Days

Paxlovid (300/100) oral tablet therapy pack — Quantity Limit: 120 EA Per 365 Days

Pemazyre (oral tablet 4.5 mg, 9 mg) — Quantity Limit: 30 EA Per 30 Days

Perampanel (oral tablet 2 mg–12 mg) — Quantity Limit: 30 EA Per 30 Days

Pirfenidone (oral tablet 267 mg) — Quantity Limit: 180 EA Per 30 Days

Pitavastatin Calcium (oral tablet 1 mg, 2 mg) — Quantity Limit: 45 EA Per 30 Days

Qulipta (oral tablet 10 mg, 30 mg, 60 mg) — Quantity Limit: 30 EA Per 30 Days

QVAR RediHaler (inhalation aerosol breath activated 40 mcg/act) — Quantity Limit: 10.6 GM Per 30 Days

Repaglinide (oral tablet 0.5 mg, 1 mg) — Quantity Limit: 150 EA Per 30 Days

Quantity limits — examples

Listed medications and their quantity limits (partial section of a larger formulary/quantity limit document).

Rexulti (oral tablet 0.25 mg–3 mg) — Quantity Limit: 240 EA Per 30 Days (selected formulations also show 30 EA Per 30 Days for specific strengths)

Rinvoq LQ (oral solution 1 mg/mL) — Quantity Limit: 240 EA Per 30 Days; Rinvoq (oral tablet extended release 15 mg) — Quantity Limit: 240 EA Per 30 Days

Risperidone (oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg) — Quantity Limits vary by strength (examples: 240 EA Per 30 Days equating to 90 EA or 30 EA Per 30 Days depending on formulation)

Roflumilast (oral tablet 250 mcg) — Quantity Limit: 240 EA Per 30 Days (also shown as 28 EA Per 365 Days for a specific reporting)

Rubraca (oral tablet 200 mg, 250 mg, 300 mg) — Quantity Limit: 240 EA Per 30 Days (equates to 120 EA Per 30 Days for listed strengths)

Rybelsus (Formulation R2) (oral tablet 1.5 mg, 4 mg) — Quantity Limit: 240 EA Per 30 Days (examples include 60 EA Per 365 Days and 30 EA Per 30 Days for specific formulations)

Trikafta (oral tablet therapy pack 50-25-37.5 & 75 mg) — Quantity Limit: 84 EA Per 28 Days (listed among Trikafta/Trintellix/Trulicity group)

Zejula (oral tablet 100 mg, 200 mg, 300 mg) — Quantity Limit: 30 EA Per 30 Days

Coding & Example Limits

Formulary flagsmixed

QL	Formulary 'Requirements/Limits' indicator denoting a quantity limit on the drug

Mixed product quantity limits (R... series)mixed

Rexulti - Quantity Limit: 240 EA Per 30 Days; RINVOQ LQ - Quantity Limit: 240 EA Per 30 Days (also 450 ML Per 30 Days for oral solution); Rinvoq - Quantity Limit: 240 EA Per 30 Days; Risperidone (various formulations) - Quantity Limits: 240 EA Per 30 Days with specific per-strength limits (30 EA/90 EA per 30 Days); Roflumilast - Quantity Limit: 240 EA Per 30 Days (also 28 EA Per 365 Days); Rubraca - Quantity Limit: 240 EA Per 30 Days (also 120 EA Per 30 Days); Rybelsus (Formulation R2) - Quantity Limits: 240 EA Per 30 Days (also 60 EA Per 365 Days and 30 EA Per 30 Days)

T... series quantity limitsmixed

Trikafta - Quantity Limit: 84 EA Per 28 Days; Trintellix - Quantity Limit: 30 EA Per 30 Days; Trulicity - Quantity Limit: 2 ML Per 28 Days; Truqap - Quantity Limit: 64 EA Per 28 Days; Tukysa - Quantity Limit: 120 EA Per 30 Days

inv-06: example quantity limit — 90 EA Per 30 Days (varies by product)

Example quantity limit90 EA Per 30 Days (varies by product)

ContextListed as a common maximum for several products in the formulary excerpt (e.g., Adempas and others)

ApplicabilityApplies to drugs on the Independent Health Medicare Advantage Part D formulary where a 'Quantity Limit' is specified

inv-07: Zejula monthly limit — 30 EA Per 30 Days

Zejula monthly limit30 EA Per 30 Days

Product detailZEJULA ORAL TABLET 100 MG, 200 MG, 300 MG

SourceListed on Independent Health Medicare Advantage Part D formulary excerpt

How to Request Quantity Exceptions

Prior Authorization

Request coverage determination for quantities above limit

If a member requires a quantity greater than the formulary limit, the member, designated representative, or provider can request a coverage determination.

Contact Medicare Member Services at 1-800-665-1502 (TTY 711) for assistance with coverage determination requests.

Billing Rule

Qulipta quantity limit — 30 EA per 30 days

QULIPTA oral tablets (10 mg, 30 mg, 60 mg) are limited to 30 each per 30 days. Providers should bill no more than this quantity unless a coverage determination has been approved.

Billing Rule

Qvar RediHaler quantity limit — 10.6 GM per 30 days

QVAR REDIHALER (inhalation aerosol, breath activated 40 mcg/act) is limited to 10.6 grams per 30 days. Billers must adhere to this weight-based monthly limit unless an exception is authorized.

Billing Rule

Repaglinide quantity limit — 150 EA per 30 days

Repaglinide oral tablets (0.5 mg, 1 mg) are limited to 150 each per 30 days. Submit a coverage determination request if a larger quantity is clinically necessary.

Key Terms

inv-12: Quantity Limit (QL) — definition

Definition (QL)Coverage provided only up to the limits specified on formulary; requests for greater quantity require a coverage determination.

Who can request moreThe member, designated representative, or provider can request a coverage determination for quantities above the limit.

Formulary flagDrugs with limits are listed with a 'QL' in the Requirements/Limits column of the formulary.

inv-13: Quantity Limit — number of units or volume allowed per specified time period

Quantity Limit — basic meaningNumber of units or volume allowed per specified time period (e.g., EA per 30 days, GM per 30 days)

Examples of unitsEA (each), GM (grams), ML (milliliters) as shown in the formulary listings

Illustrative periodsCommon periods in the document include Per 30 Days, Per 28 Days, and Per 365 Days

Policy Summary

PayerIndependent Health

PolicyQuantity Limits — Medicare Advantage Part D Formularies

Policy CodePolicy N/A

Change TypeNo material change

Effective Date6/1/2026

Next Review DateN/A

Key ActionIf a greater quantity than specified is required, the member, designated representative, or provider can request a coverage determination.

SourceLink

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