CurrentIndependent HealthPolicy N/A

Quantity Limits — Medicare Advantage Part D Formulary

Defines quantity limits applied to specific drugs on Independent Health's 2026 Medicare Advantage Enhanced Part D formulary and explains how members or providers may request coverage determinations for quantities above the limits; affects Independent Health Medicare Advantage Part D members and their prescribers.

Policy Summary

PayerIndependent Health

PolicyQuantity Limits — Medicare Advantage Part D Formulary

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date6/1/2026

Next Review DateN/A

Key ActionIf a greater quantity than the specified quantity 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

6/1/2026effective date

multiplelisted medications

1-800-665-1502contact

Quantity Limit Examples and Rules

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Adempas oral tablet — Quantity Limit: 90 EA per 30 days.

Advair HFA inhalation aerosol — Quantity Limit: 12 GM per 30 days.

Aimovig subcutaneous solution auto-injector — Quantity Limit: 1 ML per 30 days.

Alosetron HCl oral tablet 0.5 mg — Quantity Limit: 60 EA per 30 days.

Ambrisentan oral tablet 5 mg — Quantity Limit: 30 EA per 30 days.

Aripiprazole oral dispersible tablet — Quantity Limit: 60 EA per 30 days.

Budesonide inhalation suspension — Quantity Limit: 120 ML per 30 days.

Buprenorphine transdermal patch (weekly) — Quantity Limit: 4 EA per 28 days.

Dihydroergotamine mesylate nasal solution — Quantity Limit: 8 ML per 28 days.

Digoxin oral tablet 125 mcg — Quantity Limit: 35 EA per 30 days.

Epinephrine auto-injector — Quantity Limit: 2 EA per 30 days.

Eliquis (various pack forms) — examples: 444 EA per 30 days; 590 EA per 30 days; 148 EA per 30 days.

Mounjaro auto-injector (various strengths) — Quantity Limit: 2 ML per 28 days.

Omnipod kits — kit: 1 EA per 365 days; pods: 15 EA per 30 days.

Ozempic pen-injector (various strengths) — Quantity Limit: 3 ML per 28 days.

Paxlovid therapy packs — examples: 80 EA per 365 days; 44 EA per 365 days; 120 EA per 365 days.

Rinvoq oral solution — Quantity Limit: 450 ML per 30 days (also listed with 240 EA per 30 days for tablet form).

Rybelsus formulations — examples: 60 EA per 365 days; 30 EA per 30 days.

Formulary Markers and Example Limits

Formulary limit markermixed

QL	Quantity Limit designation in formulary Requirements/Limits column

Examples of Quantity Limits (QL)

Adempas90 EA per 30 days

Advair HFA (inhalation aerosol)12 GM per 30 days

Aimovig (auto-injector)1 ML per 30 days

Budesonide (inhalation suspension)120 ML per 30 days

Buprenorphine (transdermal patch weekly)4 EA per 28 days

How to Request Coverage Beyond the Quantity Limit

Prior Authorization

Request coverage determination for quantities above QL

If a member needs more than the formulary’s listed Quantity Limit (QL), the member, their designated representative, or the provider may request a coverage determination from Independent Health. Contact Medicare Member Services at 1-800-665-1502 (TTY 711) for assistance; service hours vary by season as noted in the policy. The formulary may change at any time, and members will be notified when necessary.

Request can be submitted by the member, designated representative, or provider.
Medicare Member Services phone: 1-800-665-1502; TTY 711.
Member services hours: Oct 1–Mar 31: daily 8 a.m.–8 p.m.; Apr 1–Sep 30: Mon–Fri 8 a.m.–8 p.m.
Formulary may change at any time; notice will be provided when necessary.

Terminology

Quantity Limit (QL) — definition

DefinitionQuantity Limit (QL): a formulary designation indicating coverage is provided only up to the specified limit for that drug.

Formulary markerDrugs with 'QL' are listed in the Requirements/Limits column of the formulary.

Coverage beyond limitIf a greater quantity is required, the member, designated representative, or provider can request a coverage determination.