Dispensing limits are edits that prevent prescription claims from being processed and paid by the health plan if a member is receiving more than the clinically appropriate amount of medication over a stated period of time.
The objective of dispensing limits is to improve the quality of pharmaceutical care in order to obtain appropriate outcomes and to address inappropriate utilization at the time of dispensing to minimize health risks and reduce overall costs.
Limits are typically developed based on FDA-approved drug labeling.
Metallic Drug List Dispensing Limits
Basic Drug List Dispensing Limits
Basic Annual Drug List Dispensing Limits
Balanced Drug List Dispensing Limits
Enhanced Drug List Dispensing Limits
Enhanced Annual Drug List Dispensing Limits
Performance Drug List Dispensing Limits
Performance Annual Drug List Dispensing Limits
Performance Select Drug List Dispensing Limits
These drug lists provide a listing of all the drug classes and drugs that are subject to dispensing limits.
Dispensing Limit Override Physician Fax Forms
The link above will take you to a list of current forms on the Prime Therapeutics website. If your drug request is not listed in the drug categories on the page, please use the Standard Dispensing Limit Override form. This form should be completed by the prescribing physician and faxed to the Prime Therapeutics Clinical Review Department at 1-877-243-6930. If you have questions or need additional information, call 1-800-289-1525.
Prime Therapeutics LLC is a separate pharmacy benefit management company contracted by Blue Cross and Blue Shield of Texas (BCBSTX) to provide pharmacy benefit management and related other services. BCBSTX, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.