Submit PA form and documentation for PA‑marked/non‑formulary drugs

Providers must complete and submit the Ambetter Prior Authorization (PA) form and include all required supporting documentation when requesting coverage for non‑formulary drugs or any product noted with 'PA' on the formulary. Urgent PA requests will be answered within 24 hours and non‑urgent requests within 72 hours (unless state law requires faster response); a denied PA notice will state the specific reasons for disapproval or identify missing information needed to complete the request.

• Complete Ambetter PA form and supply all requested clinical information.
• Expect urgent PA response within 24 hours and non‑urgent within 72 hours.
• Denial notices will include reasons for denial or identify missing material information.

Adalimumab biosimilars require PA and must meet QL/packaging limits

Multiple adalimumab presentations and biosimilars are subject to prior authorization and specific quantity limits (e.g., QL(0.143 EA daily); package/180‑day package limits). Providers must request PA and document dosing/indication consistent with the formulary entry when prescribing these products.

• Adalimumab variants (including ADALIMUMAB‑AATY/ADAZ/ADBM/RYVK, HUMIRA) list ILimits = QL(0.143 EA daily) and PA; some forms show package(s) per 180 day(s) limits.
• Include documentation of intended dosing and any prior biologic therapy as part of the PA request.

Obtain PA and document dosing for specialty/inhaled/infused agents

High‑cost specialty agents (examples: ARIKAYCE, ACTEMRA) are managed with prior authorization and product‑specific quantity limits; providers must obtain PA and document clinical necessity and dosing per the formulary limits.

• ARIKAYCE entries indicate ILimits = PA (Tier 4) — obtain PA prior to dispensing.
• ACTEMRA ACTPEN/ACTEMRA SOLN have QL entries (e.g., QL(3.6 mL per 28 day(s) retail; 4 mL per 28 day(s) mail) and some presentations list PA or SP; include dose/frequency in PA documentation.

Prior authorization required for listed opioid and select analgesic products

Several opioid and selected non‑opioid products are designated 'PA' on their formulary lines; providers must secure prior authorization before coverage will be approved for these listed products.

• Opioid entries frequently show 'New starts limited to 7 day supply' and PA for certain formulations — confirm PA before dispensing beyond allowed initial supply.
• Examples include hydrocodone, hydromorphone, and combination analgesic products that list PA alongside QL or new‑start restrictions.

Obtain PA for products with ILimits = PA shown on formulary rows

Some formulary entries explicitly show ILimits = PA (examples include albendazole and certain enoxaparin presentations). When ILimits = PA appears on the product line, providers must obtain prior authorization prior to coverage adjudication.

• Albendazole is listed with ILimits = PA and requires PA for coverage.
• Enoxaparin SOSY 60 MG/0.6ML entries show ILimits = PA — obtain PA where indicated.

Do not dispense PA‑marked drugs without approved prior authorization

Multiple products in the formulary are marked 'PA' — providers must submit prior authorization for these items to be considered for coverage. Do not dispense expecting automatic coverage when a PA flag is present.

• Examples of PA‑marked items include SPRAVATO, certain anticonvulsants, and others shown in the formulary.
• Claims for PA‑flagged drugs may be denied if no approved prior authorization is on file.

Request PA and include dosing/indication for PA‑listed diabetes/GLP‑1 agents

Selected branded and specialty diabetes agents (e.g., OZEMPIC, TRULICITY and combination products) list PA and QL; providers must request PA and document the indication and dosing consistent with the formulary requirements.

• OZEMPIC entries show ILimits = QL and PA (e.g., QL(0.108 ML daily); PA).
• TRULICITY is listed with QL(0.143 ML daily) and PA for some presentations — include clinical rationale with PA request.

Obtain PA for products explicitly designated PA in product lines

Certain formulary rows are designated 'PA' and require prior authorization before coverage (examples shown throughout product lists); providers must obtain PA per the formulary entry to avoid claim denial.

• Review the product line for ILimits = PA and submit PA accordingly.
• Examples span anti‑infectives, antifungals, and other therapeutic classes where PA is indicated.

PA required for specialty/tier‑4 oncology and biologic agents

Many specialty and tier‑4 agents — including selected oncology and biologic therapies (examples: LENVIMA, MVASI, ZIRABEV) — require prior authorization and may be routed through specialty pharmacy; providers must submit PA and follow specialty routing when indicated.

• LENVIMA lists ILimits = QL and PA; MVASI and ZIRABEV are Tier 4 with ILimits = PA.
• Specialty (SP) designation may require dispensing via a participating specialty pharmacy network.

Follow XIFAXAN age and QL rules and obtain PA when required

XIFAXAN 200 mg is listed with quantity limits (e.g., QL(3 EA daily; 9 EA per 3 day(s) retail)) and an age‑related PA note (At least 12 yrs old); providers must ensure age and QL requirements are met and obtain PA where noted.

• Confirm member meets age requirement (At least 12 yrs old) where specified.
• Adhere to QL (3 EA daily; 9 EA per 3 days retail) or request PA for exceptions.

Submit PA (and SP routing if shown) for oncology/specialty agents

Selected oncology and specialty drugs are annotated with 'PA' or 'SP; PA' (examples: TAGRISSO, GILOTRIF, VECTIBIX) — providers must submit prior authorization and any specialty‑pharmacy routing documentation required for coverage.

• TAGRISSO 40 mg notes QL(2 EA daily) and PA; many oncology entries list SP; PA.
• Include clinical indication, prior therapies, and dosing in PA requests for antineoplastics.

Obtain PA and follow ST where entries are flagged PA/ST

Certain products in this segment are flagged PA or ST (e.g., FANAPT marked PA; STRIBILD marked PA); providers must obtain prior authorization (and follow step therapy when ST is present) before coverage is approved.

• FANAPT lists QL and PA; STRIBILD lists QL and PA.
• If ST is present, evidence of required prior therapy may be necessary with the PA.

Arrange PA and specialty‑pharmacy fulfillment when SP or SP; PA flagged

Some drugs/formulations require both prior authorization and specialty pharmacy fulfillment (SP; PA). When a product is annotated with SP or 'SP; PA', providers must obtain PA and arrange dispensing through an appropriate specialty pharmacy network.

• Examples include certain verapamil CP24 formulations, UPTRAVI, and ADEMPAS which list PA and/or SP.
• Confirm participating specialty pharmacy and include SP routing details with the PA submission.

Obtain PA and document age/dosing for isotretinoin and PA‑marked topical acne products

Isotretinoin (10–40 mg) and multiple topical combination acne products are marked 'PA' and have age and quantity restrictions (e.g., isotretinoin QL(60 GM per 30 day(s))). Providers must request PA and document age, indication, and dosing.

• Isotretinoin requires PA and has QL(60 GM per 30 day(s)) noted.
• Topical benzoyl peroxide and combination products may include AL and PA — include age and clinical justification in PA.

Prior authorization required for listed topical antifungals and combinations

Multiple topical products and strengths (examples: luliconazole, ketoconazole topical) include 'PA' in their formulary lines; providers must obtain prior authorization per the entry prior to coverage.

• Luliconazole and ketoconazole topical entries indicate ILimits = PA; follow PA procedures before dispensing.
• Confirm any associated QL or max‑fill restrictions in the formulary row.

Request PA and follow max‑fill/interval rules for specialty/bone agents

Certain specialty/bone agents (e.g., EUCRISA, PROLIA, pamidronate, risedronate, teriparatide) include PA or SP flags and max‑fill/interval limits. Providers must secure PA and adhere to max‑fill per 180‑day or other interval restrictions when noted.

• PROLIA entries show max fill(s) per 180 day(s) — obtain PA and observe fill interval limits.
• Pamidronate disodium SOLN and pamidronate entries are SP; PA — arrange specialty dispensing and PA as required.

PA required for non‑FDA uses of digestive enzyme preparations

Digestive enzyme products (e.g., CREON, ZENPEP) indicate that non‑FDA approved uses require prior authorization. Providers seeking coverage for off‑label enzyme use must submit PA documenting the non‑FDA indication and clinical rationale.

• CREON and ZENPEP entries state 'Non‑FDA approved uses require Prior Authorization'.
• Include supporting clinical documentation when requesting PA for non‑FDA uses.

Obtain PA for the multiple PA‑noted products or classes to avoid denial

Many listed products and classes (examples: pamidronate disodium, ACTHAR GEL, tolvaptan, octreotide, various biologics) have 'PA' noted; providers must obtain prior authorization where indicated to prevent claim denial.

• ACTHAR GEL and ACTHAR GEL PEN list ILimits = PA — submit PA prior to dispensing.
• Tolvaptan and octreotide entries indicate QL and PA — include dosing and indication with PA.

Follow step therapy (ST) when formulary entries indicate ST

Step therapy (ST) applies where indicated on the formulary; when a product row includes 'ST', providers must document that required preferred alternatives were tried (or submit justification) before coverage of the listed product will be approved.

• Lisdexamfetamine entries include ILimits = ST — confirm prior step therapy trials when submitting PA.
• If a member has trialed the required alternative, include that documentation with the PA request.

Document required prior trial (e.g., 'Must try ibuprofen') for ACTEMRA SOLN 200

One ACTEMRA SOLN 200 entry explicitly states 'Must try ibuprofen', indicating a step therapy requirement; providers must document trial of the required agent before coverage will be approved for that ACTEMRA presentation.

• ACTEMRA SOLN 200 entry: 'Must try ibuprofen' is specified — include evidence of ibuprofen trial in PA documentation.
• If clinical contraindication to the required step exists, document rationale in the PA request.

Consider tier assignments — higher tiers often imply PA/ST and specialty routing

Formulary tier assignments (e.g., Tier 1A, 1B, 2, 3, 4) indicate coverage placement and may imply required step edits or higher cost sharing. Providers should consider tier when prescribing and follow any PA/ST flags associated with higher tiers.

• Tier 4/specialty items often require PA and may need specialty pharmacy fulfillment.
• Lower tiers (1A/1B) are preferred; when higher‑tier agents are requested, check for PA or ST requirements.

No explicit step sequences in extract — document rationale if seeking exception

This extract shows tier and administrative flags but does not define explicit step‑therapy sequences or required prior failures; when ST is indicated, follow the product‑level note or submit PA with clinical justification if step cannot be met.

• Where ST is flagged but no sequence is detailed, include clinical rationale in PA to support exception.
• Contact the plan for specific step‑therapy sequences not specified in the formulary extract.

Tiering can imply step therapy; include prior therapy evidence when requesting higher‑tier drugs

Tier assignments in the formulary may imply step therapy pathways (e.g., preferred drugs in tiers 1A/1B before higher‑tier alternatives). If a prescriber requests a higher‑tier agent, include evidence of prior therapy with preferred alternatives or submit PA explaining the clinical need.

• Use tiering as a guide — check product row for ST/PA flags and include prior treatment history when requesting PA.
• If step therapy is being bypassed, provide clinical justification in the PA submission.

Follow D+/D indicators and PA/QL on insulin and antidiabetic entries

Some insulin and antidiabetic entries include 'D+' or 'D' style indicators and PA/QL flags which suggest step edits or dispensing restrictions; providers should follow those indicators and submit PA/documentation when the formulary requires it.

• Examples include HUMULIN R U‑500 and multiple GLP‑1/insulin products that list QL and PA.
• If dispensing exceeds QL or deviates from 'D+' logic, include supporting documentation or request PA.

Follow ST flags on combination products (document prior therapies or request PA)

Some combination products and specific drugs show ST flags (e.g., EDARBI ILimits = QL(1 EA daily); amlodipine‑olmesartan entries marked ST). Providers must follow the ST requirement or document justification in a PA.

• EDARBI shows ILimits = QL(1 EA daily); ST — document prior therapy if required.
• Amlodipine‑olmesartan entries are marked ST — include trial of preferred alternative or PA justification.

Check PA/ST on antihypertensives and provide prior trial documentation when required

Some antihypertensive entries include PA or tiering that may reflect step edits; when prescribing these agents check the formulary line for ILimits = PA or ST and include prior therapy documentation if required for coverage.

• Examples: select antihypertensive combinations list ILimits = PA or ST — submit PA with prior trial history or medical rationale.
• Check QL values and D+/D indicators that may affect pharmacy adjudication.

Adhere to step therapy for products labeled 'ST' or provide justification in PA

A number of products are explicitly marked 'ST' or carry ST‑style indicators (e.g., apomorphine hydrochloride SOCT); providers must adhere to step therapy rules where present or include clinical justification when requesting PA.

• Apomorphine hydrochloride SOCT lists ILimits = PA and QL and marks ST — obtain PA and document prior steps.
• If step therapy cannot be met for clinical reasons, include that information with the PA.

Document trials or exceptions when ST is required

When a product row includes 'ST', providers must follow step therapy requirements prior to coverage; if step therapy is bypassed, provide clinical justification and supporting documentation with the PA to prevent denial.

• Some products labeled ST require documented trial of lower‑tier alternatives before coverage.
• Include dates, agents, durations, and clinical response in PA documentation when seeking exception.

Comply with combined SP/PA or D+ notations on product lines

Some formulary entries combine SP; PA or 'D+' notations indicating specialty dispensing plus prior authorization or dispensing restrictions; providers must comply with both specialty routing and PA requirements to ensure coverage.

• Where SP; PA appears (e.g., select oncology or pulmonary agents), coordinate specialty pharmacy fulfillment and submit PA.
• 'D+' indicators may require specific dispensing logic at the pharmacy; confirm with plan/pharmacy.

Document age limits and ST for topical dermatologic products

Several topical and dermatologic product rows include ST flags and age limits (AL); providers must document age eligibility and any required step therapy when requesting PA or filling prescriptions for these agents.

• Benzoyl peroxide and clindamycin topical entries list AL(At least 12 yrs old) and ST — confirm member age and prior therapy evidence.
• Isotretinoin entries require PA and have AL and QL requirements; include these in PA documentation.

Follow ST on topical corticosteroids or provide PA justification

Some topical corticosteroid and related products carry 'ST' indicators — providers must follow the step requirement or supply PA justification to avoid coverage denial at claim adjudication.

• Entries like alclometasone and other corticosteroid topicals include ST and QL — include prior therapy details when requesting PA.
• Pharmacies will enforce QL and max‑fill intervals noted on product lines.

Obtain PA for bisphosphonate/bone agents and follow SP where shown

Bisphosphonate/bone density products may be tiered and have PA or specialty requirements (e.g., FOSAMAX PLUS D lists ILimits = PA); providers must request PA and follow specialty routing where required.

• FOSAMAX PLUS D ILimits = QL(0.143 EA daily); PA — include clinical rationale and prior fracture/therapy history as applicable.
• PROLIA and pamidronate entries show SP; PA or max‑fill per 180 days — coordinate specialty pharmacy and PA submission.

When steps are implied by tiering, include prior therapy evidence with PA

Tier assignments can imply step edits but explicit step sequences are not provided in this extract; when seeking coverage for higher‑tier drugs include documentation of prior therapies and clinical rationale in the PA request.

• If formulary does not list explicit step sequence, use prior therapy history and clinical justification to support PA.
• Contact plan for full step‑therapy rules if needed.

Complete PA form and note plan response times for urgent/non‑urgent requests

Providers must complete the Ambetter Prior Authorization form and submit all required information; urgent requests will be responded to within 24 hours and non‑urgent requests within 72 hours (unless state law requires faster response).

• Use the Ambetter PA form and include all requested clinical information.
• Expect 24‑hour turnaround for urgent PA requests and 72 hours for non‑urgent.

Document package and 180‑day max‑fill limits (e.g., adalimumab) in PA requests

Some products have package or max‑fill limits per specified windows (e.g., many adalimumab presentations show package(s) per 180 day(s) and 1 max fill(s) per 180 day(s)). Providers should confirm and document intended packaging/fill frequency in PA submissions.

• Adalimumab entries show package limits per 180 days and 1 max fill per 180 days — include intended dispensing schedule in PA.
• Where max‑fill per period applies, document clinical need for exceptions when requesting PA.

Document and justify continuation beyond 7‑day new‑start opioid limits

New starts for many injectable and oral opioid formulations are limited to a 7‑day supply; providers must document justification and request PA to continue therapy beyond the new‑start limit.

• New‑start limit of 7 days applies to many opioid formulations — provide documentation of acute vs chronic need when requesting continuation.
• If ongoing therapy is required, submit PA with clinical rationale for supply beyond 7 days.

Adhere to QL values on product rows or request PA when exceeding limits

Many formulary entries include explicit quantity limits (QL) — providers and dispensing pharmacies must adhere to these QLs or submit PA/documentation to exceed them.

• Examples include QL(2 GM daily) for nitroglycerin (intra‑anal), QL(4 EA daily) for alprazolam strengths, and QL(900 ML per 30) for rivaroxaban suspension.
• If a prescription exceeds QL, submit PA and supporting documentation to request an override.

Record/adhere to QLs (e.g., XARELTO, enoxaparin) — exceptions require documentation

Pharmacies and prescribers should record adherence to quantity limits: QL notations (e.g., XARELTO SUSR QL 900 mL per 30 days; enoxaparin SOLN QL(6 mL daily)) will be enforced and may require documentation for exceptions.

• XARELTO suspension QL(900 ML per 30 day(s)) and enoxaparin SOLN QL(6 ML daily) are enforced at point of sale.
• When requesting exceptions, include dosing regimen and clinical justification in PA.

Include PA documentation for GLP‑1 and specialty insulin products marked PA/QL

Selected GLP‑1/insulin and other specialty antidiabetic products list PA alongside QL; providers must include PA documentation to support medical necessity when prescribing these agents.

• OZEMPIC, TRULICITY and certain insulin presentations show QL and PA flags — include prior therapy and indication in PA submissions.
• Claims for these agents may be denied without an approved PA.

Observe QLs on antifungals and related agents or submit PA for exceptions

Additional products across classes include QL notations (examples: antifungals, antifungal suspensions); providers must ensure prescriptions conform to the stated QL or submit PA with clinical justification.

• Itraconazole CAPS ILimits = QL(4 EA daily); CRESEMBA CAPS ILimits = PA.
• If prescribing beyond QL, include rationale and prior treatments in PA request.

Provide full medical‑necessity documentation for specialty antineoplastics and PA‑marked agents

Prescribers should provide documentation supporting medical necessity for specialty antineoplastic antibodies and other PA‑marked specialty agents; include prior therapies, staging, biomarkers, and dosing in the PA submission.

• Oncology biologics (e.g., TAGRISSO, VECTIBIX, MVASI, ZIRABEV) list PA and often SP; include relevant clinical details in PA.
• Lack of detailed documentation may result in PA denial or request for additional information.

Exceeding QLs may cause denials — submit PA with supporting documentation

Quantity limit edits (QL(...)) are enforced and can cause claim denial or require overrides; when a prescription exceeds the QL, providers must submit PA and documentation to support the exception.

• QL notations across the formulary will be enforced at claim adjudication.
• Include dosing, clinical reason, and duration when requesting override via PA.

Adhere to fill‑frequency and max‑fill restrictions or request PA for exceptions

Follow quantity‑limit and fill‑frequency restrictions noted on product lines (e.g., per‑day, per‑fill, 1 max fill every 90/180 days); pharmacies will enforce these and PA may be required for additional supply.

• Examples include 'Limit 1 fill every 90 days' and per‑180‑day package limits — include requested fill frequency with PA.
• Ensure pharmacy claims align with QL and max‑fill intervals or obtain PA.

Confirm age limits and include age in PA documentation for AL/PA‑listed products

For many products, age limits (AL) are specified alongside PA (e.g., tacrolimus topical entries); providers must document member age and obtain PA when PA is indicated by the formulary.

• Tacrolimus topical entries list AL(At least 2 yrs old) and PA — verify member age and include in PA documentation.
• Topical acne entries include AL(At least 12 yrs old) plus PA for some products.

Reference product‑level Tier and ILimits in PA/claims to ensure correct adjudication

Formulary product lines specify Tier, ILimits and Drug Requirements/ILimits which must be honored during claims processing and authorizations; providers should reference the exact formulary row when submitting PA or answering pharmacy inquiries.

• Ensure PA submissions reference the formulary product row and its ILimits (PA, QL, ST, AL) to expedite review.
• Pharmacies will adjudicate claims against the Tier/ILimits values; missing PA may result in denial.

Denial notices will state specific reasons or missing information — respond promptly

If a prior authorization request is disapproved, the plan's denial notice will include the specific reasons for denial or identify missing information necessary to complete the request; providers should review the notice and submit any requested information promptly.

• Denial notices will give clear reasons for disapproval or list missing material information.
• Respond to denial notices with the requested documentation or an appeal as appropriate.