CurrentIndependent HealthPolicy N/A

Quantity limits for drugs on Independent Health Medicare Advantage Part D formularies

Defines quantity limits (QL) applied to specific drugs on Independent Health's Medicare Advantage Part D formulary and explains how members or providers may request greater quantities; applies to members and providers using Independent Health's Medicare Advantage Standard Part D formulary.

Policy Summary

PayerIndependent Health

PolicyQuantity limits for drugs on Independent Health Medicare Advantage Part D formularies

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review Date

Key ActionIf a greater quantity than the specified limit 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.

multipledrugs with specified quantity limits in this part of the document

30/28/365 daystypical quantity limit timeframes used

examples: 90 EA/30d, 1 ML/30dsample quantity limits from the list

Medicare Member Servicesmember support phone and hours

30 EAcommon 30-day limit seen for multiple oral tablets

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Quantity Limit Coverage Rules

Quantity limit coverage rules

Covered up to the listed quantity; process when the limit is insufficient:

ALL of the following

Drugs listed with 'QL' on the formulary will be covered only up to the specified quantity limit.
If a greater quantity than the specified limit is required, the member, designated representative, or provider may request a coverage determination.
Medicare Member Services phone and TTY numbers and hours are provided for questions and assistance (contact: 1-800-665-1502; TTY 711; seasonal hours noted in the formulary).

examples

Selected examples of quantity limits extracted from the formulary (representative entries from the list):

ALL of the following

Rybelsus oral tablet 3 mg: 60 EA per 365 days; Rybelsus 7 mg: 30 EA per 30 days.

ALL of the following

Spiriva Respimat inhalation aerosol (1.25 mcg/act; 2.5 mcg/act): 4 GM per 30 days.

ALL of the following

Trulicity subcutaneous solution auto-injector (0.75, 1.5, 3, 4.5 mg/0.5 mL): 2 ML per 28 days.

ALL of the following

Venclexta starting pack therapy pack (10, 50, 100 mg): 42 EA per 30 days.

ALL of the following

Vowst oral capsule: 60 EA per 30 days (alternate entry: 12 EA per 3 days).

ALL of the following

Xpovio therapy packs: example limits per 28 days vary by regimen (examples include 8 EA, 4 EA, 24 EA, 32 EA depending on pack and dosing schedule).

Formulary Designation and Sample Limits

Formulary designationmixed

QL flag in formulary

Drugs listed with 'QL' in the Requirements/Limits column indicate quantity limits apply

Mixed product limitsmixed

Multiple products with varied quantity limits (Rexulti, Rinvoq, risperidone, roflumilast, Rubraca, Rybelsus R2) listed; specific per-item limits noted in source

Sample quantity limit thresholds

90 EA per 30 daysAdempas oral tablet — Quantity Limit: 90 EA Per 30 Days

1 ML per 30 daysAimovig subcutaneous solution auto-injector 70 MG/ML — Quantity Limit: 1 ML Per 30 Days

180 EA per 30 daysPirfenidone oral tablet 267 mg — Quantity Limit: 180 EA Per 30 Days

120 EA per 30 daysAUSTEDO oral tablet 9 mg — Quantity Limit: 120 EA Per 30 Days

Trikafta therapy pack limit

84 EA per 28 daysTRIKAFTA oral tablet therapy pack (50-25-37.5 & 75 mg) — Quantity Limit: 84 EA Per 28 Days

Actions for Providers and Members

Prior Authorization

Request a coverage determination for quantities above limits

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

Billing Rule

Qulipta quantity limit: 30 EA per 30 days

Quantity Limit: 30 EA Per 30 Days for Qulipta oral tablets (10 mg, 30 mg, 60 mg).

Billing Rule

Qvar RediHaler quantity limit: 10.6 GM per 30 days

Quantity Limit: 10.6 GM Per 30 Days for Qvar RediHaler (40 mcg/act).

Terms and Index

QL (Quantity Limit)

Definition'QL' indicates a quantity limit is applied to the drug on the formulary; coverage is provided only up to the specified limit.

Formulary markingDrugs subject to quantity limits are listed with 'QL' in the Requirements/Limits column of the formulary.

Effect on coverageIf a drug has a QL, Independent Health will provide coverage only up to the listed quantity limit.

Coverage determination

What it isCoverage determination — a request that a member, designated representative, or provider may submit when a greater quantity than the formulary limit is clinically required.

Who may submitThe member, their designated representative, or the provider may submit the request for a coverage determination.