CurrentIndependent HealthPolicy N/A

Medicare Advantage Part D quantity limits (formulary)

Defines quantity limits applied to medications on Independent Health's 2026 Medicare Advantage C-SNP Part D formulary and describes how members/providers can request coverage determinations for quantities above limits.

Policy Summary

PayerIndependent Health

PolicyMedicare Advantage Part D quantity limits (formulary)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date5/1/2026

Next Review DateN/A

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.

2026formulary year

5/1/2026document effective

C-SNP Part Daffected formulary

~70+sample limits

Quantity Limits and Coverage Criteria

Quantity limits and exceptions process

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Quantity-limit criteria set

Per-product quantity limits that determine maximum dispense amounts and intervals for outpatient pharmacy claims. Examples below are drawn from the formulary list (limits shown exactly as in source).

RYBELSUS ORAL TABLET 3 MG — Quantity Limit: 60 EA Per 365 Days.

RYBELSUS ORAL TABLET 7 MG — Quantity Limit: 30 EA Per 30 Days.

STIOLTO RESPIMAT INHALATION AEROSOL (2.5-2.5 MCG/ACT) — Quantity Limit: 4 GM Per 30 Days.

TRULICITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR (various strengths) — Quantity Limit: 2 ML Per 28 Days.

VIVJOA ORAL CAPSULE THERAPY PACK 150 MG — Quantity Limit: 18 EA Per 84 Days.

WEGOVY formulation-dependent

WEGOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.25 MG/0.5ML, 0.5 MG/0.5ML, 1 MG/0.5ML — Quantity Limit: 2 ML Per 28 Days.
WEGOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 1.7 MG/0.75ML, 2.4 MG/0.75ML — Quantity Limit: 3 ML Per 28 Days.

XIFAXAN ORAL TABLET 200 MG — Quantity Limit: 9 EA Per 3 Days.

ZEJULA ORAL TABLET (100/200/300 MG) — Quantity Limit: 30 EA Per 30 Days.

XPOVIO therapy packs (various strengths) — example limits: 8 EA Per 28 Days (pack-specific EA adjustments shown in formulary).

Additional sample entries (representative): TRUQAP ORAL TABLET THERAPY PACK 160/200 MG — 64 EA Per 28 Days; VENCLEXTA ORAL TABLET 10 MG — 60 EA Per 30 Days; VENCLEXTA STARTING PACK THERAPY PACK — 42 EA Per 30 Days; many other drugs listed with per-interval EA/ML/GM limits throughout the formulary.

Formulary Entries and Quantity Specifications

Formulary drug entries with limitsmixed

ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT	Quantity Limit: 90 EA Per 30 Days = Quantity Limit: 12 GM Per 30 Days
AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 70 MG/ML	Quantity Limit: 90 EA Per 30 Days = Quantity Limit: 1 ML Per 30 Days
alosetron hcl oral tablet 0.5 mg	Quantity Limit: 90 EA Per 30 Days = Quantity Limit: 60 EA Per 30 Days
ambrisentan oral tablet 5 mg	Quantity Limit: 90 EA Per 30 Days = Quantity Limit: 30 EA Per 30 Days
aripiprazole oral tablet dispersible 10 mg, 15 mg	Quantity Limit: 90 EA Per 30 Days = Quantity Limit: 60 EA Per 30 Days
asenapine maleate sublingual tablet 2.5 mg, 5 mg	Quantity Limit: 90 EA Per 30 Days = Quantity Limit: 60 EA Per 30 Days
AUSTEDO ORAL TABLET 6 MG	Quantity Limit: 90 EA Per 30 Days = Quantity Limit: 60 EA Per 30 Days
AUSTEDO ORAL TABLET 9 MG	Quantity Limit: 90 EA Per 30 Days = Quantity Limit: 120 EA Per 30 Days
AUSTEDO XR ORAL TABLET EXTENDED RELEASE 12 MG, 18 MG	Quantity Limit: 90 EA Per 30 Days = Quantity Limit: 30 EA Per 30 Days

medication quantity entriesmixed

RYBELSUS ORAL TABLET 3 MG	Quantity Limit: 60 EA Per 365 Days
RYBELSUS ORAL TABLET 7 MG	Quantity Limit: 30 EA Per 30 Days
sacubitril-valsartan oral tablet 24-26 mg, 49-51 mg	Quantity Limit: 60 EA Per 30 Days
SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG	Quantity Limit: 60 EA Per 30 Days
SCEMBLIX ORAL TABLET 20 MG	Quantity Limit: 60 EA Per 30 Days
SCEMBLIX ORAL TABLET 40 MG	Quantity Limit: 300 EA Per 30 Days
SECUADO TRANSDERMAL PATCH 3.8 MG/24HR	Quantity Limit: 30 EA Per 30 Days
sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg	Quantity Limit: 10 EA Per 30 Days
SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100-33 UNT-MCG/ML	Quantity Limit: 15 ML Per 25 Days
SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG	Quantity Limit: 30 EA Per 30 Days

Examples of numeric quantity thresholds

30 EA Per 30 DaysCommon per-product limit format used across formulary entries (example: ERLOTINIB: 90 EA Per 30 Days).

3 ML Per 28 DaysExample of volume-based limit for injectable/pen products (example: TRULICITY/WEGOVY entries show ML-based limits).

60 EA Per 365 DaysAnnualized limit format used for some products (example: RYBELSUS 3 mg: 60 EA Per 365 Days).

1 EA Per 365 DaysLow-frequency limit format for infrequently dispensed products (example formats present in document).

444 EA Per 30 DaysHigh-count pack limit shown for specific pack-configured products (example: ELIQUIS 1.5 mg pack).

Xpovio therapy pack limits (examples)

8 EA Per 28 DaysCommon therapy-pack baseline quantity limit applied to many Xpovio therapy-pack entries (e.g., XPOVIO 40/60/80 mg variants show 8 EA per 28 days).

16 EA Per 28 DaysPack-adjusted example where a 10 mg therapy pack maps to 16 EA per 28 days for a specific presentation.

4 EA Per 28 DaysPack-adjusted example where a 40 mg or 60 mg therapy pack results in a 4 EA per 28 days dispensed amount.

24 EA Per 28 DaysHigher pack-adjusted example shown for certain twice-weekly presentations mapping to 24 EA per 28 days.

32 EA Per 28 DaysMaximum example shown for a twice-weekly 20 mg therapy pack mapping to 32 EA per 28 days.

How to Request Coverage Beyond Limits

Prior Authorization

How to request a coverage determination for quantities above the limit

If a member requires a quantity greater than the limit shown in the formulary, the member, the member's designated representative, or the prescribing provider may request a coverage determination. Requests may be submitted by phone to Medicare Member Services at 1-800-665-1502 (TTY 711). Member Services hours: October 1–March 31: daily 8 a.m.–8 p.m.; April 1–September 30: Monday–Friday 8 a.m.–8 p.m. Include clinical rationale and supporting documentation showing medical necessity for the increased quantity when submitting the request. Appeals and exceptions will be processed in accordance with Medicare Part D appeals and exceptions rules.

Request may be made by member, designated representative, or provider
Provide clinical rationale and supporting documentation
Contact Medicare Member Services: 1-800-665-1502 (TTY 711) — hours vary by season

Documentation Required

Quantity limits — sample entries

Sample quantity-limit entries illustrate how limits are expressed and what to expect when prescribing. Examples from the formulary: RYBELSUS ORAL TABLET 3 MG — Quantity Limit: 60 EA per 365 days; RYBELSUS ORAL TABLET 7 MG — Quantity Limit: 30 EA per 30 days; SACUBITRIL-VALSARTAN ORAL TABLET (24-26 mg, 49-51 mg) — Quantity Limit: 60 EA per 30 days; SAVELLA ORAL TABLET (12.5 mg, 25 mg, 50 mg, 100 mg) — Quantity Limit: 60 EA per 30 days; SCEMBLIX ORAL TABLET 20 MG — Quantity Limit: 60 EA per 30 days; SCEMBLIX ORAL TABLET 40 MG — Quantity Limit: 300 EA per 30 days; SECUADO TRANSDERMAL PATCH 3.8 MG/24HR — Quantity Limit: 30 EA per 30 days; SILDENAFIL CITRATE ORAL TABLET (25 mg, 50 mg, 100 mg) — Quantity Limit: 10 EA per 30 days; SOLIQUA SUBCUTANEOUS SOLUTION PEN 100-33 UNT-MCG/ML — Quantity Limit: 15 ML per 25 days.

RYBELSUS 3 mg: 60 EA per 365 days
RYBELSUS 7 mg: 30 EA per 30 days
Sacubitril-Valsartan (24-26 mg, 49-51 mg): 60 EA per 30 days
Scemblix 20 mg: 60 EA per 30 days; Scemblix 40 mg: 300 EA per 30 days
Secuado patch 3.8 mg/24hr: 30 EA per 30 days

Billing Rule

Device/product-specific limits — inhaler and unit examples

Some products and delivery devices have limits expressed in units other than tablets (EA) — e.g., inhaler canisters (GM) or milliliters (ML). Examples: SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG — Quantity Limit: 30 EA per 30 days; SPIRIVA RESPIMAT / STIOLTO RESPIMAT / STRIVERDI RESPIMAT inhalation aerosols — Quantity Limit: 4 GM per 30 days; SUNOSI ORAL TABLET 75 MG — listed as 4 GM per 30 days (equates to 45 EA per 30 days in formulary mapping); TADALAFIL oral tablet (10 mg, 20 mg ED) — 4 GM per 30 days (mapped to 6 EA per 30 days); Tadalafil 2.5 mg, 5 mg — 4 GM per 30 days (mapped to 30 EA per 30 days); TAZVERIK ORAL TABLET 200 MG — 4 GM per 30 days (mapped to 240 EA per 30 days). When prescribing device-based products, confirm the unit of measure (GM, EA, ML) and the applicable time window (per 30 days, per 365 days) before submitting a prior authorization or exception request.

Spiriva HandiHaler (capsules): 30 EA per 30 days
Spiriva Respimat / Stiolto Respimat / Striverdi Respimat: 4 GM per 30 days
Sunosi 75 mg: 4 GM per 30 days (mapped to 45 EA per 30 days)
Tadalafil 10/20 mg (ED): 4 GM per 30 days (mapped to 6 EA per 30 days)
Tazverik 200 mg: 4 GM per 30 days (mapped to 240 EA per 30 days)

Key Terms and Unit Abbreviations

Quantity limits (QL) — definition

DefinitionQuantity limits (QL) are the specified maximum amounts of a drug that will be covered within a defined time period (e.g., per 30 days).

PurposeIndicates the maximum dispense amount the formulary will cover without a coverage determination.

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

Coverage determination — definition

Who may requestA member, the member's designated representative, or the provider may request a coverage determination for quantities above the specified limit.

When to requestWhen a greater quantity than the specified limit is required to meet a member's clinical needs.

EffectA coverage determination requests coverage of quantities beyond the formulary-specified limits; it is the formal process to seek approval for the excess quantity.

Unit abbreviations used in quantity limits

EAEach — unit count used for tablets, capsules, inhaler canisters, etc.

GMGrams — weight unit used for some inhalation products (e.g., RESPIMAT entries list GM per 30 days).

MLMilliliters — volume unit used for liquid formulations and injectable pens (examples appear in formulary entries).

therapy packCombined tablet/capsule pack presentation shown in listings; therapy-pack limits are expressed as EA per interval and may map to different EA values depending on pack strength.