Centene Ambetter 2025 Formulary Coverage Update

Coverage summary

Scope summary: This document is Ambetter Health’s 2025 Prescription Drug Formulary (effective January 1, 2025; last reviewed October 1, 2025) and defines covered FDA‑approved brand and generic drugs organized into copay tiers (0, 1A, 1B, 2, 3, 4). The formulary favors generics when available, is periodically reviewed and updated, and applies plan‑specific limitations where noted.

Formulary structure and tiering (high level): Ambetter’s formulary lists covered medications by tier with specialty drugs placed in a designated specialty tier that may require dispensing through participating specialty or hemophilia network pharmacies. Tiers are defined as: Tier 0 (no copayment for certain preventive/mandated drugs), Tier 1A and 1B (lower copayment generic/low‑cost choices), Tier 2 (preferred brands/medium copay), Tier 3 (higher copay/non‑preferred), and Tier 4 (specialty/highest copay and special handling).

Overall coverage stance: mixed — the formulary includes many covered drugs but applies product‑specific operational flags and restrictions such as Quantity Limits (QL), Age Limits (AL), Prior Authorization (PA), Step Therapy (ST), Specialty dispensing (SP), and Split Fill (SF) where indicated; plan or benefit design may further restrict coverage. Providers and pharmacies should follow listed flags and the prior authorization process (urgent: response within 24 hours; non‑urgent: 72 hours) when applicable.

Document metadata

Effective date2025-01-01

Last review2025-10-01

StatusCURRENT

Document segment/partPart 13 of 15

Scope summaryDefines Ambetter Health's 2025 prescription drug formulary: tiers, coverage principles, prior authorization and limits (quantity limits, age limits, step therapy, specialty fill rules) and selected drug-specific tier/limit/PA entries included in this part of the formulary.

Opioid new-start limits (highlight)New starts limited to 7 day supply: up to two 7-day fills during any 28-day period; up to 28 non-consecutive days supply in any 90-day period (cumulative across all opioids); prior authorization required for fills exceeding limits.

Initial therapy / general coverage criteria

Drug-specific flags & examples

This brief contains numerous formulary line items. Each listed line item in this fragment may include: a formulary Tier assignment, Quantity Limits (QL) (per day, per fill, or per time period), Age Limits (AL), and operational flags such as Prior Authorization (PA), Step Therapy (ST), and Specialty (SP).

The examples and groups shown in the brief (not exhaustive) are drawn from the extracted fragment and include opioid analgesics with new‑start 7‑day limits and QL values, numerous specialty biologic injectables with QL and PA/SP flags, antivirals/antiretrovirals with QL and PA, inhaled respiratory agents with QL, vaccines with seasonal/annual max‑fill limits, and many topical/dermatologic items with AL/QL/PA annotations.

Applicable codes (formulary lines / NDCs)

Formulary entries with tier, limits, and PAmixedCovered

acetaminophen TABS 325 MG-10 MG / 325-5 MG / 325-7.5 MG	Oral tablets combinations and strengths — formulary entry includes tiering, quantity limits, and prior authorization as specified per plan.
buprenorphine hcl SOLN / SUBL / PTWK / PTWK (various)	Buprenorphine formulations for opioid use disorder — multiple product lines; subject to specialty tiering, PA, and dispensing limits.
dofetilide	Antiarrhythmic agent — listed with PA requirement and monitoring criteria.
FASENRA PEN/SOSY	Benralizumab products — specialty tier; PA and site-of-care limitations apply.
NUCALA	Mepolizumab — specialty tier; PA required for continuation and initial therapy.
XOLAIR	Omalizumab — specialty biologic; PA and quantity limits per dosing schedule.
cromolyn sodium NEBU	Nebulized cromolyn — respiratory agent with tiering and quantity limits.
ATROVENT HFA	Ipratropium inhaler HFA — formulary respiratory product; tier and QL as listed.
AIRDUO / AIRSUPRA / albuterol (various forms)	Combination and short-acting beta agonist inhalers and nebulized albuterol products — multiple lines included with tiering and quantity limits.
ANORO ELLIPTA, ANORO/TRELEGY/BREO etc.	Long-acting bronchodilator/combination inhalers — specialty or higher tiers with PA for certain strengths/forms.

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Provider actions & billing impacts

Prior Authorization

Prior authorization required for non-formulary drugs and many specialty/biologic products

Prior authorization is required for non-formulary drugs and many specialty/biologic products. Providers must submit a Prior Authorization (PA) request for PA-designated products, some strengths, and certain agents (including many specialty and pulmonary hypertension products). Urgent requests will be responded to within 24 hours; non-urgent requests within 72 hours (or sooner if state law requires). If a request is denied or incomplete, the notice will specify the reasons or identify missing material information needed to complete the request.

Prior authorization required for PA-designated products, many listed specialty agents, and specific strengths
PA required pathway available for overrides when quantity/age limits are exceeded
Response time: urgent = 24 hrs; non-urgent = 72 hrs

Documentation Required

Documentation requirements and denial notice content

Documentation and denial reasons: providers must supply age and quantity limit supporting documentation when requested. Denial notices must clearly state the specific reasons for disapproval or identify missing information needed to complete the PA. Include clinical documentation that demonstrates patient meets age and quantity limit criteria where applicable.

Definitions, thresholds and limits

Key definitions used in the fragment (concise):

QL (Quantity Limit) — drug coverage restricted to a specified amount or frequency (examples shown as formats like QL(n EA daily), QL(n ML daily), or QL(n EA per fill retail)).

AL (Age Limit) — coverage limited to specified ages (examples: AL(At least 6 yrs old), AL(At least 12 yrs old), AL(At least 18 yrs old)).

PA (Prior Authorization) — provider must obtain approval from Ambetter before coverage; PA requests for urgent cases: response within 24 hours, non‑urgent: 72 hours once complete information received.

ST (Step Therapy) — requirement to try specified preferred therapy first before alternative is covered.

SP (Specialty Drug) — specialty designation; may require fulfillment at participating specialty or hemophilia network pharmacies and additional handling.

SF (Split Fill) — initial limited supply (often 15‑day increments) until stabilization; restriction may end after 90 days.

RXIOTC — prescription required even though OTC alternative exists (notation used in the formulary).

Threshold	Value
Opioid new-start supply limits	New starts limited to 7‑day supply: up to two 7‑day fills during any 28‑day period; up to 28 non‑consecutive days supply in any 90‑day period (applies cumulatively across opioid medications).
Examples of 'New starts limited to 7 day' on formulary lines	Multiple opioid entries annotated 'New starts limited to 7 day supply' (e.g., codeine, morphine, oxycodone, tramadol and many combinations).
Quantity limit examples (QL)	Formulary shows many per‑product quantity limits such as QL(1 EA daily), QL(2 EA daily), QL(3 EA daily), QL(6 EA daily), QL(12 EA daily), QL(0.34 EA daily), QL(0.143 EA daily), QL(180 ML daily), QL(100 ML daily), and multiple per‑fill or per‑period caps.
Naloxone limits (example)	Naloxone liquid: QL(2 EA per retail); 2 max fills per 30 days retail; naloxone solution lines show 365 day retail / 3 max day(s) mail entries per formulary lines.
Ondansetron limits (example)	Ondansetron tablet examples: QL(3 EA daily; 45 EA per fill retail) for 8 mg; QL(60 EA per fill retail) for 4 mg; solution and IV forms have per‑day mL QL entries.
Seasonal vaccine limits	Seasonal vaccines limited to 1 dose per season or specified max fills per period (examples: limit 1 dose per season; max fills per 180 days or 365 days shown for influenza, pneumococcal and other vaccines).
Age limits (AL) examples	Some products include age limits (e.g., aripiprazole tablets: at least 6 years old; various entries show AL(At least 12 yrs old); SHINGRIX: at least 18 yrs old).
Other named example limits	LUCEMYRA (lofexidine) QL example: QL(224 EA per 14 days); illustrative per‑product QL/PA flags and max‑fill windows appear across the formulary.

Clinical evidence & rationale

No randomized‑trial metrics are provided in the brief fragment: the evidence section is not included here and the extract contains operational coverage rules and item‑level flags rather than clinical trial data.

Embedded rationales in criteria/operational rules (documented in the criteria trees) include public‑health or utilization controls and programmatic handling. Examples shown in the fragment: opioid public‑health limits for new starts (restricting new opioid starts to 7‑day supply with cumulative caps over defined windows, and PA for exceptions) and specialty distribution/handling for many biologic injectables (QL and SP/PA flags indicating specialty pharmacy routing and prior authorization requirements).

Revision history

2025-01-01Effective

Formulary effective date as published: Effective January 1, 2025.

2025-10-01Last reviewLatest

Formulary last reviewed/updated: Ambetter Formulary updated October 2025 (last review date shown as 2025-10-01).

OpenPayer

Ambetter Health 2025 Formulary (prescription drug list)