CurrentIndependent HealthPolicy N/A

Quantity Limits (Pharmacy Benefit Dimensions PDP Part D Formulary)

Lists quantity limits for specific drugs on the Pharmacy Benefit Dimensions (Independent Health) formularies and explains that coverage is limited to the specified quantities; applies to members and providers using the listed PDP Part D formularies.

Policy Summary

PayerIndependent Health

PolicyQuantity Limits (Pharmacy Benefit Dimensions PDP Part D Formulary)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2026

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

May 1, 2026date list is current as of

PDP Part D 3 Tieraffected formulary

Multiplequantity limit entries

Member servicesupport contact

30 daysmost limits expressed per

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distinct entries in excerpt

Quantity Limit Coverage Criteria

Quantity limit examples

Selected examples from the list (partial):

ADEMPAS ORAL TABLET 0.5 mg, 1 mg, 1.5 mg — Quantity Limit: 90 EA Per 30 Days

AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 70 MG/ML — Quantity Limit: 1 ML Per 30 Days

alosetron hcl oral tablet 0.5 mg — Quantity Limit: 60 EA Per 30 Days

buprenorphine transdermal patch weekly (5-15 mcg/hr) — Quantity Limit: 4 EA Per 28 Days

EPINEPHRINE auto-injector — Quantity Limit: 2 EA Per 30 Days

Per-drug quantity limit entries

Per-drug quantity limits as listed below apply for benefit adjudication.

Exxua (FETZIMA) oral capsule extended release 24 hour 20 mg, 40 mg, 80 mg — Quantity Limit: 30 EA per 30 days

Fluticasone propionate Diskus inhalation powder (various strengths) — Quantity Limit: typically 30 EA per 30 days (some strengths listed as 60 EA per 30 days)

Gabapentin (once-daily) 300 mg tablet — Quantity Limit: 90 EA per 30 days

Hydromorphone HCl oral tablet 2 mg, 4 mg — Quantity Limit: 360 EA per 30 days

Methadone HCl oral tablet 5 mg — Quantity Limit: 240 EA per 30 days

Methylphenidate HCl ER (various formulations/strengths) — Quantity Limit: ranges from 30 EA to 180 EA per 30 days depending on formulation

Index-only excerpt

This excerpt contains only an alphabetical listing of drugs/formulations subject to quantity limit consideration; it does not include explicit coverage criteria or numeric limits.

Alphabetical index excerpt (partial): Adempas; Advair HFA; Aimovig; Alosetron HCl; Ambrisentan; ARIPiprazole; Asenapine Maleate; Austedo; Austedo XR; Austedo XR Patient Titration; Ayvakit; Belsomra; Bosentan; Bosulif; Breyna; Breztri Aerosphere; Brivaracetam; Briviact; Budesonide; Budesonide‑Formoterol Fumarate; Buprenorphine; Camzyos; Caplyta; Carvedilol Phosphate ER; cloNIDine; Coartem; Cobenfy Starter Pack; CombiPatch; Copiktra; Dapagliflozin Propanediol; Darifenacin Hydrobromide ER; Dasatinib; Daurismo; Desvenlafaxine ER; Dexmethylphenidate HCl ER; Digoxin; Dihydroergotamine Mesylate; Dimethyl Fumarate; Dotti; Doxepin HCl; Drizalma Sprinkle; Droxidopa; Eliquis; Eliquis (1.5 MG Pack); Eliquis (2 MG Pack); Eltrombopag Olamine; Eohilia; EPINEPHRINE; ... (list continues in full index)

Drug-Level Coding & Periods

Examples of drug-specific quantity limitsNDC | mixedCovered

No codes listed

drug-level quantity entriesmixed

Multiple oral tablet and capsule products with specified numeric quantity limits per time interval

N/A in excerptmixed

No codes listed

Common period thresholds

Per 30 daysMost quantity limits are expressed per 30 days (e.g., 30 EA per 30 days; 60 EA per 30 days).

Per 28 daysSome products and therapy/titration packs use a 28-day interval (e.g., 4 EA per 28 days for weekly transdermal patches; 2 ML per 28 days for Wegovy entries).

Per 365 daysA few agents use annual caps expressed per 365 days (e.g., Paxlovid entries with limits like 80 EA per 365 days).

Per 3 days / short-course packsCertain therapy packs use short intervals (example: Xifaxan 9 EA per 3 days).

Per 21 days / 42 daysSome specialty kits use other intervals (e.g., Winrevair kits: 1 EA per 21 days or 2 EA per 21 days; Xdemvy 10 ML per 42 days).

Actions for Providers and Members

Prior Authorization

Requesting a coverage determination for quantities above limits

Pharmacy Benefit Dimensions has established quantity limits on certain drugs listed on the formulary (marked with 'QL'). Coverage is provided only up to the specified limits. If a greater quantity is medically necessary, the member, designated representative, or provider may request a coverage determination.

Contact Medicare Member Services: 1-800-667-5936 (TTY 711). Oct 1–Mar 31: daily 8 a.m.–8 p.m. ET; Apr 1–Sep 30: Mon–Fri 8 a.m.–8 p.m. ET.
Quantity limits are indicated on the formulary with 'QL' and may change; members will be notified when necessary.

Note

Quantity limits listing (examples)

Examples of quantity limits (per 30 days) for specific products and formulations are shown below. These are illustrative excerpts from the formulary and represent how limits are listed.

Exxua (Fetzima) extended‑release oral capsules 20 mg, 40 mg, 80 mg — Quantity Limit: 30 each per 30 days.

Key Definitions

Definition: Quantity Limit (QL)

What 'QL' meansDrugs marked with 'QL' on the formulary are covered only up to the specified limit; coverage beyond that requires a coverage determination by the member, representative, or provider.

Where indicatedThe 'QL' designation appears in the Requirements/Notes column of the formulary to signal the applied limit for adjudication.

How to request moreIf a greater quantity is required than specified, the member, designated representative, or provider can request a coverage determination.

Definition: Quantity Limit (maximum allowed within time interval)

Units and intervalsQuantity limits specify the maximum allowed units using units such as EA, GM, ML, or ML per 365 days within a defined interval (e.g., per 30 days, per 28 days, per 365 days).

Examples of units

Policy Summary

PayerIndependent Health

PolicyQuantity Limits (Pharmacy Benefit Dimensions PDP Part D Formulary)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2026

Next Review DateN/A

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

SourceLink

On This Page

Ozempic pen‑injector (various doses) — Quantity Limit: 3 ML per 28 days

Paxlovid (150/100) and other Paxlovid entries — Quantity Limits expressed as annual caps per 365 days (examples include 44 EA per 365 days; 120 EA per 365 days)

Wegovy subcutaneous solution auto‑injector (various strengths) — Quantity Limit: 2–3 ML per 28 days depending on strength

Xpovio (various weekly dosing schedules) — example entries include 8 EA per 28 days with alternate pack conversions

Note: This module contains many additional drug‑specific quantity limit entries; examples above are not exhaustive — full list present across chunks 18–35.

Common 30-day cap (examples)

Per-30-day cap (most common)Many formulary entries are limited per 30 days (examples: ADEMPAS 90 EA per 30 days; Fluticasone Diskus 30 EA per 30 days; Aimovig 1 ML per 30 days).

Variations within 30-day framingSome strengths use different 30-day caps (e.g., Fluticasone Diskus listed as 30 EA per 30 days or 60 EA per 30 days depending on strength).

Large numeric 30-day capsCertain products have unusually large 30-day caps (examples: Eliquis pack entries showing 444 EA or 590 EA per 30 days in the listing).

Quantity limit formulations listed

Multiple strengths per productSome products appear multiple times with different strengths and dosing schedules (e.g., Xpovio with 40/60/80/100 mg entries across once- or twice-weekly regimens).

Different formulations listed separatelyA single brand may have pen-injector, ML limits, or EA limits depending on dose/form (e.g., Ozempic entries with 3 ML per 28 days across several dose formulations).

Therapy/titration packsTherapy packs are listed with pack-specific limits (e.g., Austedo XR patient titration therapy pack: 28 EA per 28 days).

Fluticasone propionate Diskus inhalation powder 50 mcg/act, 100 mcg/act — Quantity Limit: 30 each per 30 days (or formulation‑specific limits up to 60 each per 30 days as noted).

Fluticasone propionate HFA inhalation aerosol 110 mcg/act — Quantity Limit: 30 each per 30 days (example alternate measurement: 12 g per 30 days for some strengths).

Fluticasone‑salmeterol inhalation aerosol powder — Quantity Limit examples: 30 each per 30 days or 1 each per 30 days for specific preparations.

Fosfomycin tromethamine — Quantity Limit: 1 each per 30 days for single‑dose packet formulation.

Gabapentin (once‑daily) 300 mg tablet — Quantity Limit: 90 each per 30 days.

Note

Formulary index excerpt — drugs/formulations with quantity limits (partial)

Partial formulary index excerpt showing products and formulations that are subject to quantity limits. Refer to the full formulary for complete, current listings.

Sample list includes (not exhaustive): Adempas; Advair HFA; Aimovig; Austedo (and XR); Breztri Aerosphere; Brivaracetam; Budesonide and Budesonide‑Formoterol formulations; Buprenorphine; Copiktra; Eliquis (including pack variants); Eltrombopag; and many others. Entries marked with 'QL' in the formulary indicate a quantity limit applies.

Examples in the formulary include EA (each), GM (grams), ML (milliliters) and days-based pack counts (e.g., 9 EA per 3 days).

Interval variabilityIntervals vary by product type and pack (common intervals: 30 days, 28 days, 21 days, 3 days, 365 days).

Formulary index (partial)

Partial formulary indexThis document includes a partial alphabetical index of drugs and formulations that are subject to quantity limits; the excerpt does not always show full numeric limits or administrative rules for every line.

Reference to full listThe index excerpt points to detailed per-drug entries elsewhere in the formulary (many additional quantity limit entries are present across the document).

Use in adjudicationThe index helps locate drugs subject to QL policy but adjudication depends on the specific per-drug quantity limit entries in the full list.