Quantity Limit Program - BCBSM
SC = subcutaneous, mg = milligram, gm = gram, mcg = microgram, ml = milliliter, IU = international unit Not covered: You may be responsible for the full cost of the medication. Not applicable: Quantity limits may not apply. Sample Abilify MyCite = brand name (aripiprazole) = generic name Quantity limits for: Medication BCBSM Clinical ,CustomClosed
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www.bcbsm.comclaims faster, and it can reduce your out-of coverage information. If you don’t have other coverage, please indicate that on the form and return it to us.
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Required Document Reference List - bcbsm.com
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