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Quantity Limits

Wellmark typically covers a 30-day supply for prescriptions. Large groups, however, can customize this benefit.

In addition, some prescriptions are limited to a specified maximum quantity. Amounts over this quantity are not a covered benefit.

The following drugs have a quantity limit:

Prescription Name:	Limitations:
Amerge	9 tablets per 30 days
Axert	12 tablets per 30 days for retail
Celebrex	60 capsules per 30 days (also requires prior authorization)
Cialis	6 tablets per 30 days (also requires prior authorization)
Frova	9 tablets per 30 days
Imitrex	9 tablets, 6 injections, or 6 bottles of nasal spray per 30 days
Lamisil	12-week limit for non-immunocompromised patients
Levitra	6 tablets per 30 days (also requires prior authorization)
Maxalt	9 tablets per 30 days
Migranal	6 bottles per 30 days
Mobic	30 tablets per 30 days (also requires prior authorization)
Muse	6 doses per 30 days
Relpax	6 tablets per 30 days
Stadol NS	2 bottles (2.5 ml each) per 30 days
Viagra	6 tablets per 30 days (also requires prior authorization)
Zomig	6 tablets per 30 days, or 6 nasal spray units per 30 days

Quantity limits are in place for these drugs to ensure the medication is being used correctly and other treatments are not appropriate. Most people would not need to take these drugs more often than what is allowed.

No special steps are necessary by the physician or member to have these drugs covered as long as the medications are prescribed within the limitations. In rare cases, a drug may also require prior authorization in addition to the quantity limit (e.g. Viagra).

If you require one of these drugs in a larger quantity than is allowed, your physician may make a special request for coverage. Your physician may be asked to provide details about your medical condition and treatment plan. After reviewing the information, coverage will be evaluated based on medical necessity.

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Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association doing business in Iowa and South Dakota. Blue Cross®, Blue Shield®, and the Cross® and Shield® symbols are registered marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.