Ambetter Health 2025 Formulary (prescription drug list)
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Defines 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.
No material changes to clinical coverage or formulary rules in this 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.
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)
| 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. |
Provider actions & billing impacts
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 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.
- Denial notice must specify specific reasons for disapproval or list missing material information required
- Age-limit examples to document: aripiprazole age restrictions and SHINGRIX seasonal/age criteria (follow age-based coverage constraints)
- Quantity limit examples to document: naloxone quantity limit thresholds and other QL-enforced products — adhere to QL per fill and daily/unit caps
Specialty dispensing, mail vs retail limits, and specialty designation
Specialty dispensing and billing rules: specialty-designated (SP) drugs may be routed to participating specialty pharmacies and have distinct fill/fulfillment rules versus retail/mail. Quantity limits, fill frequency, and maximum-fill windows must be enforced at dispensing; vaccines and seasonal products have specific per-fill/day and max-fill constraints.
- Specialty pharmacy routing required for SP-designated drugs (fulfill at participating specialty or hemophilia network pharmacies)
- Retail vs mail differences: some drugs may have different QL or allowable days-per-fill depending on retail vs mail fulfillment
- Enforce quantity limits at the time of dispensing: per-fill, per-day, and max-fill window rules apply (including seasonal/annual vaccine limits)
Step therapy requirements and examples
Step therapy (ST) edits apply to selected agents. Some products require staged therapy or trials of preferred agents before coverage of alternatives. Examples include certain stimulant products (e.g., lisdexamfetamine may be subject to step edits) and select pulmonary hypertension agents; follow the step therapy flags when submitting claims or PA requests.
- Step therapy required for selected stimulants and other agents (example: lisdexamfetamine)
- Step edits or ST flags applied to some pulmonary hypertension products — PA and step criteria may both apply
- Follow ST requirements and document prior trials when requesting coverage for later-line agents
New-start supply restrictions and opioid initial-fill limits
New-start supply restrictions and opioid initial-fill limits must be observed and documented. Initial-fill caps and staged supply rules are enforced; providers may use the PA pathway for exceptions.
- Opioid new-starts limited to two 7-day fills during any 28-day period and up to 28 total non-consecutive days in any 90-day period (cumulative across opioids)
- New start supply restrictions: certain medications may be limited to 15-day split fills initially (SF) until stabilized; after ~90 days the restriction may be removed
- PA pathway available for overrides of initial-fill and new-start limits
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
Formulary effective date as published: Effective January 1, 2025.
Formulary last reviewed/updated: Ambetter Formulary updated October 2025 (last review date shown as 2025-10-01).
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