CurrentIndependent HealthPolicy N/A

Quantity Limits — Medicare Advantage Part D Formulary

Defines quantity limits applied to specific drugs on Independent Health's 2025 Medicare Advantage Part D formularies and explains how members or providers can request coverage for quantities above those limits.

Policy Summary

PayerIndependent Health

PolicyQuantity Limits — Medicare Advantage Part D Formulary

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~120+distinct product/formulation entries (approx)

per 30 dayscommon reporting interval

28 or 365 daysalternate intervals noted

phonemember services contact

Quantity Limits — Selected Examples

Sample drug-specific quantity limits

Policy Summary

PayerIndependent Health

PolicyQuantity Limits — Medicare Advantage Part D Formulary

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

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

SourceLink

On This Page

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Abilify MyCite Maintenance Kit — 30 EA Per 30 Days (10,15,20,30,5 mg); 60 EA Per 30 Days (2 mg)

Advair HFA — 12 GM Per 30 Days

Aimovig — 1 ML Per 30 Days

Aripiprazole (dispersible) — 60 EA Per 30 Days

Benzonatate — 30 EA Per 10 Days

Budesonide inhalation suspension — 120 ML Per 30 Days

Fentanyl buccal lozenge/on a handle — 120 EA Per 30 Days

Fluticasone propionate Diskus — 60 EA Per 30 Days

Lisdexamfetamine dimesylate — 30 EA Per 30 Days

Mounjaro (most strengths) — 2 ML Per 28 Days

Omnipod kits — 1 EA Per 365 Days; pods 15 EA Per 30 Days

Ozempic pens — 3 ML Per 28 Days

quantity limits (partial list)

This part of the policy provides per-product quantity limits; it does not include prior authorization or clinical criteria in these chunks.

QVAR REDIHALER — 30 EA Per 30 Days (also expressed as 10.6 GM Per 30 Days)

Radicava ORS — 30 EA Per 30 Days (50 ML Per 28 Days)

Radicava ORS Starter Kit — 30 EA Per 30 Days (70 ML Per 28 Days)

Repaglinide — 30 EA Per 30 Days (150 EA Per 30 Days noted for specific strengths)

Retevmo — 30 EA Per 30 Days (60 EA Per 30 Days for oral capsule; 90 EA Per 30 Days for oral tablet in some entries)

Revuforj — 30 EA Per 30 Days (240 EA Per 30 Days noted)

Rexulti — 30 EA Per 30 Days

Rinvoq LQ oral solution 1 mg/mL — 30 EA Per 30 Days (450 ML Per 30 Days)

Coding and Product Identifiers

No explicit billing or coding codes listed in this extractmixed

No codes listed

Drug/formulation listmixed

RINVOQ LQ ORAL SOLUTION 1 MG/ML

RINVOQ LQ ORAL SOLUTION 1 MG/ML: Quantity Limit: 450 ML Per 30 Days

inv-05: High-count opioid lozenges — fentanyl buccal products: 120 units per 30 days.

ProductFentanyl buccal lozenge / buccal tablet

Quantity limit120 EA per 30 Days

Formulations notedBuccal lozenge on a handle and buccal tablet (various mcg strengths)

inv-06: Xpovio therapy-pack thresholds — varied per pack and dosing frequency (examples for once- and twice-weekly dosing with per-28-day EA limits).

Therapy-pack examplesXpovio therapy packs listed with EA limits per 28 days varying by pack and dosing frequency

Once-weekly (40 mg)Quantity Limit: 8 EA per 28 Days = Quantity Limit: 16 EA per 28 Days (therapy pack 10 mg / 40 mg mapping)

Twice-weekly (40 mg)Quantity Limit: 8 EA per 28 Days = Quantity Limit: 8 EA per 28 Days (therapy pack 40 mg)

Other dose patternsMultiple entries for 60 mg and 80 mg once- and twice-weekly with corresponding per-28-day EA limits (examples provided)

Requests and Operational Notes

Note

Coverage determination for quantities above limits

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

Applies to drugs listed with 'QL' in the formulary Requirements/Limits column.
Contact Medicare Member Services at 1-800-665-1502 (TTY 711). Hours: Oct 1–Mar 31: Daily 8 a.m.–8 p.m.; Apr 1–Sep 30: Mon–Fri 8 a.m.–8 p.m.

Note

Quantity limits (partial)

The following medications have quantity limits as listed. Limits are expressed as the unit and the period (for example, "30 EA Per 30 Days" or "450 ML Per 30 Days"). This is a partial, consolidated listing from the formulary.

QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT — 30 EA per 30 days (also listed as 10.6 GM per 30 days)
RINVOQ LQ ORAL SOLUTION 1 MG/ML — 450 ML per 30 days
RADICAVA ORS ORAL SUSPENSION 105 MG/5ML — 50 ML per 28 days
RADICAVA ORS STARTER KIT ORAL SUSPENSION 105 MG/5ML — 70 ML per 28 days
repaglinide oral tablet 0.5 mg, 1 mg — 150 EA per 30 days
RETEVMO ORAL CAPSULE 40 MG — 60 EA per 30 days
RETEVMO ORAL TABLET 40 MG — 90 EA per 30 days
REVUFORJ ORAL TABLET 25 MG — 240 EA per 30 days
REXULTI ORAL TABLET 0.25–3 MG — 30 EA per 30 days
RINVOQ LQ ORAL SOLUTION 1 MG/ML — 450 ML per 30 days

Note

Quantity limits (continued)

Continued listing of medications and their quantity limits from the formulary.

risperidone oral tablet dispersible 0.25 mg, 0.5 mg — 90 EA per 30 days
risperidone oral tablet dispersible 1 mg, 2 mg — 30 EA per 30 days
roflumilast oral tablet 250 mcg — 28 EA per 365 days
ropinirole hcl er oral tablet 2–8 mg — 60 EA per 30 days
RUBRACA ORAL TABLET 200–300 MG — 120 EA per 30 days
RYBELSUS (FORMULATION R2) ORAL TABLET 1.5 MG — 60 EA per 365 days
RYBELSUS ORAL TABLET 3 MG — 60 EA per 365 days
RYBELSUS ORAL TABLET 4 MG, 7 MG — 30 EA per 30 days
sacubitril-valsartan oral tablet 24-26 mg, 49-51 mg — 60 EA per 30 days
SAVELLA ORAL TABLET 12.5–100 MG — 60 EA per 30 days
SCEMBLIX ORAL TABLET 20 MG — 60 EA per 30 days; 40 MG — 300 EA per 30 days
SECUADO TRANSDERMAL PATCH 24 HR 3.8 MG/24HR — 30 EA per 30 days
sildenafil citrate oral tablet 25–100 mg — 10 EA per 30 days
SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100-33 UNT-MCG/ML — 15 ML per 25 days
SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG — 30 EA per 30 days
SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25–2.5 MCG/ACT — 4 GM per 30 days

Key Terms

inv-11: Coverage limited to the maximum quantity specified on the formulary; requests for greater quantities require a coverage determination — Quantity limit (QL).

DefinitionCoverage is limited to the maximum quantity specified on the formulary (QL).

Action if need exceeds limitMember, designated representative, or provider can request a coverage determination for quantities above the limit.

Where indicated on formularyDrugs with limits are marked with 'QL' in the Requirements/Limits column.

inv-12: Quantity Limit — short definition entry.

TermQuantity Limit (QL)

MeaningA maximum covered amount for a drug as specified on the formulary (expressed per interval, e.g., per 30 days, per 28 days).

Provider implicationRequests for quantities beyond the QL must follow the coverage determination process.

inv-13: therapy pack / starter kit — indicates bundled tablet counts or ml volumes and their allowed dispensing interval.

What it indicatesTherapy packs / starter kits list bundled tablet counts or milliliter volumes and their allowed dispensing interval (e.g., EA per 28 days, ML per 28/30 days)

Xpovio exampleTherapy pack entries show specific EA per 28 days by pack and dosing frequency (multiple pack-size mappings provided).

Radicava exampleRadicava ORS Starter Kit: Quantity limits given as ML per 28 days in addition to EA counts.

Dispensing intervalTherapy packs/starter kits use the same period conventions as other QLs (commonly per 28 days or per 30 days).