ModifiedPremera BluecrossPolicy N/A

Drug Quantity Management

Defines quantity limits for pharmacy‑benefit drugs managed by Premera Blue Cross and the conditions under which specified quantities may be approved for members and providers.

Policy Summary

PayerPremera Bluecross

PolicyDrug Quantity Management

Policy CodePolicy N/A

Change TypeAdded targeted drugsupdated cabergoline limitadministrative reorganization

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionSubmit medical records demonstrating medical necessity including office visit notes with diagnosis, relevant history, physical evaluation, and medication history.

SourceLink

POLICY UPDATE CHANGES

Added multiple drugs (e.g., Vizz (aceclidine), adapalene-benzoyl peroxide, Arimidex, Lynkuet, memantine, Prestalia, Veozah, Xphozah, Spiriva, Trexall, Yupelri, and others) to the list of targeted drugs.

Moved quantity limit criteria from one policy (5.01.605) to another (5.01.656 Drug Quantity Management) for specified products including sensors and several drugs.

Updated cabergoline tablet quantity limit to 8 tablets per 28 days.

New policy record created and approved August 12, 2025.

2026-04-01policy effective date

12 monthsmaximum approval length

8/tabletscabergoline limit

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targeted drugs in appendices

30-dayexample appendix supply

Coverage Criteria and Applicability

Medical necessity and approval duration

Covered when ALL of the following are met:

General: Target drugs (see Appendix) may be considered medically necessary when the prescribed dose is within the US Food and Drug Administration (FDA) labeled dosing.

Quantity limits in this policy are based on the maximum or recommended FDA‑approved dose as stated in the product label; quantities in excess of the limits may be approved based on adequate published peer‑reviewed evidence.

Approval duration: Initial authorization: up to 12 months.

Re‑authorization: may be approved up to 12 months when drug‑specific coverage criteria are met.

Dispensing quantity limits are the maximum amount of a medication that may be dispensed during a given calendar period or at one prescription fill without an exception request. Dispensing of a larger quantity may be approved based on individual case review when member-specific circumstances require it or when published clinical evidence supports a higher dose protocol. Dispensing quantity limits are not intended to apply in circumstances where logistics may dictate otherwise (for example, member vacation or business travel, disruption of prescription supply chains due to weather or other disasters, or members living in remote areas where travel to a pharmacy is difficult).

This medical policy does not apply to Medicare Advantage. Providers and members should consult the member benefit booklet or contact customer service to determine whether coverage or any benefit limitations apply for a specific plan or service.

Coding

Codingmixed

No codes listed

Provider Actions and Prior Authorization

Prior Authorization

Targeted drugs subject to pharmacy edits and PA reviews

Targeted drugs listed in the policy are subject to pharmacy edits and prior authorization review. Pharmacy claims may be edited for quantity, day supply, or package/package-size limits based on the Target Drug appendix and plan-specific edit logic. If a claim triggers a pharmacy edit, submit a prior authorization request with supporting clinical documentation for review.

Targeted drugs and quantity/package specifics are defined in the Appendix.
Pharmacy edits may enforce quantity limits, day-supply limits, or package-size limits.

Denial Risk

Benefit/plan limits may trigger denial

Benefit and plan limits may result in denial even when medical necessity is otherwise met. Coverage is governed by the member's benefit plan and any applicable limits or exclusions in the member benefit booklet. This policy does not apply to Medicare Advantage — verify Medicare Advantage coverage rules separately.

Background

A quantity limit is defined as the maximum amount of a medication that may be dispensed during a specified calendar period or at a single prescription fill without an exception. These limits are established based on FDA‑approved prescribing information, manufacturer dosing, and clinical best practices. Larger quantities may be authorized following individual case review when justified by specific circumstances or supporting published evidence.

Definitions

Label / Product label definition

DefinitionProduct label refers to the FDA‑approved prescribing information for a legend drug, including indications, contraindications, recommended dosing, warnings, precautions, adverse effects, drug interactions, pharmacology, pharmacokinetics, and available dosage forms.

ContentsThe label includes recommended dosing and administration, safety information (pregnancy, special populations), and a summary of pivotal clinical trials submitted to FDA.

Source/accessPrescribing information is included as a package insert and is available on the manufacturer’s website.

Use in policyQuantity limits in this policy are based on FDA‑labeled dosing found in the product label.

Quantity limits definition

Definition

Quantity Limits and Appendix Highlights

Appendix examples — Quantity Amount / Day Supply

Example — 30/30Adapalene‑Benzoyl Peroxide: Quantity Amount = 45, Day Supply = 30 (example appendix entries show 30‑day supplies for topical pumps).

Example — Dexcom G6 SensorDexcom G6 Sensor: Quantity Amount = 3, Day Supply = 30 (sensor quantity listed per appendix).

Example — Inpen (insulin pen)Inpen (for Humalog/Novolog): Quantity Amount = 1, Day Supply = 365 (device‑level entries show annual quantities).

Quantity amounts listed across appendix entries

Common amountsMany appendix entries list Quantity Amount = 30 with Day Supply = 30 for oral tablet/capsule presentations (e.g., amphetamine ER ODT, memantine ER, metoprolol tartrate, rivaroxaban).

60‑unit examples

Site of Care / Benefit Management

Billing Rule

Pharmacy benefit management

Drugs included in this policy are managed through the pharmacy benefit; submit prescription requests and prior authorization inquiries through pharmacy benefit channels.

Use pharmacy benefit submission processes for claims and PA.
Appendix quantity limits are applied at the pharmacy benefit level.

Policy Summary

PayerPremera Bluecross

PolicyDrug Quantity Management

Policy CodePolicy N/A

Change TypeAdded targeted drugsupdated cabergoline limitadministrative reorganization

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionSubmit medical records demonstrating medical necessity including office visit notes with diagnosis, relevant history, physical evaluation, and medication history.

SourceLink

On This Page

Verify member benefits and limits in the member benefit booklet or by contacting customer service.
Denials may occur for plan exclusions, benefit maximums, or if the member’s contract does not cover the requested drug or service.

Documentation Required

Required documentation — submit medical records demonstrating medical necessity

Submit medical records that demonstrate medical necessity for all prior authorization requests. Include office visit notes with diagnosis, relevant history, physical examination, medication history, and any drug‑specific documentation requested by the plan (e.g., prior treatments, dosing rationale). Incomplete or insufficient documentation may delay review or result in denial.

Include diagnosis, relevant history, physical evaluation, and medication history in office visit notes.
Provide documentation of prior therapies, response to treatment, and rationale for requested dose/quantity.
Re-authorization requests must demonstrate ongoing medical necessity; approvals may be for up to 12 months when criteria are met.

Quantity limits = the maximum amount of a medication that may be dispensed during a given calendar period or at one prescription fill without an exception request.

ExceptionsDispensing of a larger quantity may be approved based on individual case review when member‑specific circumstances or published clinical evidence support it.

Logistics noteLimits are not intended to apply in circumstances where logistics dictate otherwise (e.g., member travel, supply‑chain disruption, remote locations).

AdministrationQuantity limits and targeted drug lists are used for pharmacy edits and prior authorization determinations; policy history documents additions and updates to limits.

Some inhaler or blister presentations list Quantity Amount = 60 with Day Supply = 30 (e.g., Umeclidinium‑Vilanterol, Rivaroxaban 60 units listings, Xphozah 60).

Device or sensor exceptionsSensors/transmitters and certain devices list different quantities (e.g., Dexcom sensors = 3/30; transmitters = 1/90).

Long‑duration devicesCertain devices/pens list annual quantities (e.g., Inpen quantity = 1, Day Supply = 365).

Cabergoline (tablet) — quantity limit (updated)

DrugCabergoline (tablet) 0.5 mg

Updated limitQuantity Amount = 8 tablets per 28 days (updated in interim review and history).

SourceAppendix entry lists Cabergoline 0.5 mg tablet: Quantity Amount = 8, Day Supply = 28; update confirmed in policy history (02/01/26).