Ambetter Formulary (Prescription Drug List) — Coverage Criteria
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Defines the Ambetter prescription drug formulary, tiering, prior authorization, quantity limits, step therapy, specialty pharmacy requirements, and opioid prescribing limits for members covered under the plan.
No material clinical or coverage changes in this revision.
Formulary Coverage & Conditions
Formulary coverage
Formulary coverage principles
Check member benefit for plan‑specific coverage and cost share.
Non-Formulary Drug PA
Prior authorization for non-formulary drugs
Denial notices will state specific reasons or identify missing information.
Opioid limits
Opioid prescribing limits for new starts
This limit applies cumulatively to all opioid medications filled.
Apply both the new‑start rule above and the product‑specific QL/PA as listed.
Formulary coverage entries (partial)
Coverage entries include tier, quantity limits (QL), package/maximum fills per 180 days, age limits (AL), and PA indicators.
Multiple presentations (pens, syringes, starter kits) have specific package/180‑day limits and PA requirements.
Actemra entries
Tocilizumab (ACTEMRA) formulations include specific QL per period, SP/PA flags, and in one case a prerequisite trial requirement.
Follow SP/PA and step requirement where indicated on the entry.
OTEZLA entries
PDE4 inhibitor OTEZLA has QL, PA, age limits and package limits.
Coverage restricted by age and PA as indicated on the formulary.
Formulary controls (PA, QL, new-start limits, age limits)
Coverage and utilization controls apply as follows based on formulary entries
Refer to individual product lines for specific QL, AL, SP, PA values.
Formulary coverage logic (excerpt)
Coverage and access are determined by formulary tier, quantity limits, and prior authorization where specified.
Clinical criteria or NDC‑level medical necessity rules are not included in the provided excerpt.
Formulary entries and utilization management
Coverage status and utilization management indicators per drug entry
No additional clinical inclusion/exclusion criteria are present in this segment.
Covered with formulary conditions
Coverage is tier-based and may require PA, SP, or have QL restrictions as listed per product.
Claims lacking required PA/SP or exceeding QL/AL may be denied.
Formulary coverage conditions
Coverage details per formulary entry — coverage depends on tier, age limits, quantity limits, and utilization management tags.
Follow the entry‑level AL/QL/PA/ST values for adjudication.
Formulary coverage entries (per-drug basis)
Coverage/tiering and limits applied per listed topical and outpatient drug entries
See the individual product entries (chunks referenced) for the exact QL/AL/PA values and any package/180‑day fill limits.
The formulary is a guide to FDA‑approved brand and generic medications covered under the prescription drug benefit. Please note the formulary is not a complete list of covered drugs: not all dosage forms or strengths may be covered, and the list is periodically updated. Coverage also depends on individual benefit plan design, which may impose additional limits or exclude certain products despite appearance on the formulary; verify member benefits for coverage limitations and cost‑sharing.
Within the provided excerpt there are no explicit exclusion statements describing products or categories that are categorically not covered.
This segment does not include any explicit clinical exclusion criteria (for example, diagnosis‑based or contraindication‑based exclusions) for coverage decisions.
No explicit clinical exclusion rules are stated in the excerpted formulary lines shown here; entries include tiers, quantity limits, and utilization controls but not diagnosis‑specific exclusion criteria.
In this document segment there are no explicit exclusion conditions listed that would universally deny coverage for a drug or class.
Across the supplied excerpts there are no statements labelling items as “not medically necessary”. The document instead lists formulary controls (tiers, QLs, PA/SP) without explicit not‑medically‑necessary determinations in these segments.
Some topical product entries state limits such as “Limit 1 Fill per 180 days”, which functionally exclude additional fills beyond the specified maximum; such package/180‑day fill limits should be treated as hard limits for adjudication unless overridden by an approved prior authorization.
The formulary notes that certain digestive or pancreatic enzyme preparations (e.g., CREON, ZENPEP) list that Non‑FDA approved uses require Prior Authorization. For these enzymes and some large‑unit pancreatic enzyme products, prior authorization is required for uses not included in FDA labeling.
Consistent with the enzyme entries above, the document reiterates that Non‑FDA approved uses require Prior Authorization — providers must submit a PA when requesting coverage for off‑label enzyme indications.
As noted earlier, this excerpt does not include explicit “not medically necessary” statements; coverage guidance is expressed via tiers, quantity limits, and PA/SP flags rather than categorical not‑medically‑necessary language.
Reiterating the previous observations: within these segments there are no explicit not‑medically‑necessary statements; utilization management is implemented through PA, SP, QL, and tier assignments instead.
This placeholder preserves space for any extended exclusion or coverage text that may be required when the full formulary document is referenced. Consult the full Ambetter formulary for complete product‑level rules and any additional exclusion language.
Again, in this segment there are no explicit “not medically necessary” declarations; utilization controls (for example, PA and SP) are used to govern access to many high‑cost or specialty agents.
Codes, Quantity Limits & Examples
| N/A | Drug list entries include drug names, tiers, and limits but no CPT/HCPCS/ICD-10 codes in this extract. |
| No codes listed |
| QL(2 EA daily) | Quantity limit examples as listed (EA daily) |
| QL(1 EA daily) | Quantity limit examples as listed (EA daily) |
| QL(0.0089 EA daily) | Quantity limit example present for RUXIENCE |
| No codes listed |
| not provided | Document lists drug names and formulations but no explicit CPT/HCPCS/NDC codes in this chunk |
| No codes listed |
Authorization, Documentation & Risk of Denial
Prior authorization required — non‑formulary drugs
Submit a completed Prior Authorization form with all required clinical/supporting information to request coverage for non‑formulary products; Ambetter will respond within 24 hours for urgent requests and within 72 hours for non‑urgent requests. If denied, the notice will state specific reasons or identify missing information needed to complete the request.
- Use the Ambetter Prior Authorization form and include clinical justification and any requested documentation.
- Expect urgent request response within 24 hours and non‑urgent within 72 hours (unless state law requires a faster timeline).
- Denial notices will explain specific reasons or list missing material information.
PA/SP required for many biologics — document QL and package limits
Many biologic and specialty agents are designated SP and/or PA and include package or quantity limits (e.g., adalimumab presentations list package(s) per 180 days and QL values); submit prior authorization and observe package/QL limits when requesting coverage.
- Document package(s) per 180 day(s) and any product QL (e.g., QL(0.143 EA daily) for certain adalimumab presentations).
- Prior authorization (PA) or specialty pharmacy (SP) routing is required for many biologics — requests missing PA/SP may be denied.
Follow PA/SP flags and QL on formulary entries (e.g., ACTEMRA)
Formulary entries may include PA and SP flags plus explicit QL values (example: ACTEMRA ACTPEN and SOLN list QL per 28 days and SP/PA indicators); include those flags and QL values on authorization requests.
- ACTEMRA ACTPEN: QL(3.6 mL per 28 day(s) retail; 4 mL per 28 day(s) mail); SP.
- ACTEMRA SOLN 200: QL and in some entries a prerequisite 'Must try ibuprofen' (step requirement) — document trials when applicable.
PA and documentation required for opioid new‑starts (7‑day limit)
Multiple opioid formulations are subject to prior authorization and have new‑start supply limits; for new opioid starts document indication and adhere to the 7‑day new‑start limit or request PA for supply beyond the limit.
- New starts limited to a 7‑day supply; prior authorization is required for fills beyond these limits.
- Document clinical indication and justification when requesting authorization for supply beyond the 7‑day new‑start limit.
Provide age documentation when PA/AL applies
Some products include age limits (AL) alongside PA (for example OTEZLA lists AL(At least 45 yrs old Up to 79 yrs old)); provide patient age on the PA request and ensure age criteria are met.
- When an AL is listed, include the patient’s date of birth/age on the authorization to demonstrate eligibility.
- Claims for patients outside the listed age bounds may be denied if PA and age criteria are not satisfied.
Submit prior authorization for PA‑designated products
Any product listing 'PA' in its Drug Requirements/Limits field requires prior authorization before coverage; providers must submit PA for those formulations (examples appear throughout the formulary).
- Check the Drug Requirements/Limits field for 'PA' or 'SP; PA' and submit authorization accordingly.
- Failure to submit PA for PA‑designated presentations may result in claim denial.
Confirm PA for listed product presentations (e.g., enoxaparin)
Multiple listed products (including enoxaparin presentations) include 'PA' — verify PA requirement for the exact presentation and submit authorization with the product’s QL/package info.
- Examples: enoxaparin sodium presentations list QL values and PA; include the specific formulation and QL in the PA request.
- Record package‑per‑180‑days limits where present.
PA required for select branded formulations (e.g., TRIJARDY XR, REZVOGLAR)
Certain branded and combination products (examples include TRIJARDY XR, REZVOGLAR KWIKPEN and others) are subject to prior authorization — include the product and NPI/prescriber details on the PA submission.
- TRIJARDY XR entries show QL and PA indicators — submit PA when requesting coverage.
- REZVOGLAR KWIKPEN is listed with ILimits = PA; include required documentation when submitting.
PA required for select antifungal and other agents (e.g., itraconazole CAPS)
Some specific agents are marked 'PA' in the formulary (example: itraconazole CAPS); submit prior authorization with clinical rationale for these select products.
- Itraconazole CAPS: ILimits = ... PA — include indication and dosing on the PA form.
- Other antifungals may have QL and PA; verify each formulation’s entry.
Specialty pharmacy (SP) and prior authorization required for many formulary drugs
Numerous formulary drugs include PA and/or SP flags; when a product is listed with 'SP' or 'SP; PA' route fulfillment through the specialty network and submit PA documentation as required.
- Examples: oncology/immunomodulators and many specialty injectables list SP; PA — coordinate specialty pharmacy routing.
- Include QL, package limits and clinical justification in the PA to avoid delays or denial.
Provide PA documentation for products labeled 'PA' or 'SP; PA'
Drugs explicitly labeled 'PA' or 'SP; PA' require prior authorization; providers must supply documentation consistent with those requirements to prevent coverage denials.
- Examples: PERSERIS PRSY shows QL(...)/PA; FUZEON SOLR shows SP; PA — include required clinic notes and specialty routing info.
- Claims without PA/SP for these entries may be denied.
PA required for select cardiac and pulmonary hypertension agents
Certain cardiac and pulmonary hypertension agents and strengths (e.g., verapamil CP24 strengths; TYVASO/treprostinil kits and solutions) are PA or SP; submit PA and specialty documentation when requesting these therapies.
- Verapamil CP24 100/200/300 MG: Drug RRequirements/ILimits = PA — include indication on PA.
- TYVASO starter/refill kits and treprostinil SOLN IJ: ILimits include QL and PA; route via specialty as indicated.
PA required for select topical agents — document age and indication
Certain topical clindamycin formulations and combination topical acne products list PA and age limits; submit PA and document patient age and quantity needs for coverage.
- Clindamycin phosphate topical FOAM: AL(At least 12 yrs old); PA — include DOB and indication.
- Clindamycin–benzoyl peroxide combinations: AL(At least 12 yrs old); PA — include prior topical therapy/step info if applicable.
Submit PA for topical products where 'PA' is listed
Multiple topical agents across the formulary show 'PA' in the Drug Requirements/Limits field; providers must submit prior authorization when PA is indicated for the topical formulation requested.
- Examples include clindamycin phosphate–benzoyl peroxide gel and luliconazole which list PA — attach relevant clinical notes to the PA.
- Where QL or max fills per interval appear, include supply requested and justification.
Prior authorization required when 'PA' is shown in formulary entry
Products with 'PA' in their Drug Requirements/Limits require prior authorization; providers must submit PA before dispensing to obtain coverage for those items.
- Review the Drug Requirements/Limits field for 'PA' on each product presentation before claim submission.
- Attach product‑specific clinical documentation to the PA to demonstrate medical necessity.
PA required for non‑FDA uses and select products (document indication)
Prior authorization is required for certain non‑FDA uses and specified products (examples: FOSAMAX PLUS D, some risedronate and large‑unit enzyme products); submit PA with documentation of the non‑FDA indication and rationale.
- Non‑FDA approved uses explicitly state 'Non‑FDA approved uses require Prior Authorization' — include supporting clinical rationale.
- Example: FOSAMAX PLUS D ILimits = ... PA — include indication and prior therapy when requesting PA.
Comply with Step Therapy requirements — document prior trials
Step Therapy (ST) requires members to try specified drugs before Ambetter will cover an alternative; where an entry includes 'ST' or a 'Must try' note (e.g., ACTEMRA), document prior trials on the authorization.
- When 'ST' or a 'Must try' requirement appears, include evidence of trial and failure/intolerance of preferred agent(s).
- If step requirements are not met, coverage may be denied until criteria are satisfied.
Observe ST/SP flags — try preferred agents or use specialty routing as indicated
Some formulary entries include 'SP' or 'Must try' phrasing suggesting step or specialty program controls (examples include ACTEMRA and other high‑tier agents); follow the listed ST/SP indicators when submitting requests.
- If 'SP' is listed, arrange fulfillment via Ambetter’s specialty pharmacy network and include specialty routing details on PA.
- If a 'Must try' preferred agent is listed, document the trial on the prior authorization.
Tiering may imply step access — confirm ST where present
Where step therapy sequences are not explicitly described in this excerpt, tier assignments imply preferred access but specific step requirements must be confirmed from the formulary entry and documented on PA when 'ST' is shown.
- Tiering (1A/1B/2/3/4) implies preferred access; check the specific Drug Requirements/Limits for ST language.
- If ST is flagged, document prior attempted therapies per the formulary requirement.
Document QL and package‑per‑180‑day values on PA requests
When submitting a prior authorization, include product QL/package values and any relevant package per 180‑day limits so adjudicators can validate the requested supply against formulary limits.
- Record package(s) per 180 day(s) retail/mail limits and specific QL (e.g., ACTEMRA QL per 28 days, adalimumab package per 180 days) on the PA form.
- Claims or PA requests that do not document package/QL values may be subject to denial or delay.
Document justification for opioid new‑start supply beyond 7 days
Document supply justification for new‑start opioid fills when requesting PA — new starts are limited to a 7‑day supply and prescribers should state the indication and reason for any supply beyond 7 days.
- For new opioid prescriptions, indicate the clinical reason for more than a 7‑day supply if requesting PA.
- Include prior analgesic history and any prior authorization rationale in the request.
Include formulary QL/PA values on claims and PA submissions
Use the formulary’s listed QL and PA values when completing pharmacy claims and PA submissions — entries such as ELIQUIS starter packs, naloxone limits, and biologic QLs must be reflected in the request.
- ELIQUIS STARTER PACK: QL and max fill per 180 days must be included when requesting coverage.
- Naloxone entries include QL and max fills per interval — document these when submitting PA or processing claims.
Attach required clinical documentation for PA/SP drugs
Provide clinical documentation consistent with PA requirements for drugs marked 'PA' or 'SP' (lack of necessary documentation increases risk of denial).
- Attach clinical notes, prior therapy history, labs or other required evidence to support medical necessity.
- For SP agents, include specialty pharmacy routing and any enrollment information required by the specialty program.
Include patient age/DOB for age‑limited products
When age limits (AL) apply (e.g., pimecrolimus AL(At least 2 yrs old); OTEZLA AL(At least 45 yrs old Up to 79 yrs old)), include patient age/DOB on the authorization to demonstrate eligibility.
- Claims or PA requests missing patient age evidence for AL‑restricted products may be denied.
- Document both minimum and maximum age criteria where listed.
Record product QL and AL values on PA requests and claims
Document quantity limits (QL) and age limits (AL) per product on PA requests and claims; many products (including injectables, topical and specialty agents) specify QL values that are used in adjudication.
- Examples: TYVASO STARTER KIT: QL(3 EA daily); clindamycin toppicals: QL( GM daily); naloxone SOLN: QL(4 EA daily) with max fills — include these values on requests.
- Exceeding QL or failing to provide justification may lead to denial.
If PA denied — notice will state reasons or missing information
If a prior authorization request is disapproved, the denial will explain the specific reasons or identify missing material information needed to complete the request; use that guidance to correct and resubmit if appropriate.
- Review denial notice for explicit reasons or missing documentation and provide the identified material information if resubmitting.
- Timely responses to deficiency notices may affect reconsideration timelines.
Denial risk — requests exceeding package/180‑day or QL
Requests that exceed package(s) per 180 days or exceed listed quantity limits (QL) are at risk of prior authorization denial; verify package/QL limits before submitting a request for additional supply.
- Adalimumab and some antifungal/topical entries list package or max‑fill per 180 days — exceeding those will risk denial.
- Include justification and clinical rationale if requesting exceptions to package or QL limits.
Denial risk for biologics without PA/SP and required QL
Biologic entries that list 'SP' or 'PA' plus specific QL values (e.g., RUXIENCE, TRUXIMA, COSENTYX, ADALIMUMAB presentations) may be denied if PA/SP requirements or QL restrictions are not met.
- RUXIENCE: ILimits = PA; QL(0.0089 EA daily); SP indicated — supply requests without PA/SP documentation risk denial.
- COSENTYX and other biologics list QL and PA — include QL and specialty routing on PA.
Denial risk when PA and age limits are not met
Claims for products listed with both PA and age limits may be denied if PA is not obtained or the patient’s age does not meet the AL specified on the formulary entry.
- OTEZLA entries include AL(At least 45 yrs old Up to 79 yrs old) plus PA — ensure both PA and age compliance.
- Provide DOB/age in PA to avoid age‑related denials.
Denial risk — claims missing PA for PA‑designated presentations
Products explicitly listed with 'PA' (for example amiodarone SOLN, enoxaparin presentations) indicate prior authorization is required; claims lacking PA for these PA‑designated presentations may be denied.
- Amiodarone hcl SOLN: ILimits = PA — include PA prior to claim submission.
- Enoxaparin SOSY / SOLN presentations list PA and QL — ensure PA is obtained where required.
Denial risk — exceeding specified QL without justification
Exceeding a product’s specified quantity limit (QL) without appropriate justification or override is a common cause for denial; check the QL field and attach justification if an exception is requested.
- Examples include enoxaparin QL per day values and multiple topical QLs — requests beyond these values require PA with rationale.
- PA requests should reference the exact QL expression from the formulary entry.
Denial risk when QL, SP or PA requirements are incomplete
Entries that combine QL with SP and PA (format 'QL(...); SP; PA') indicate both quantity and specialty/prior authorization controls; failure to satisfy any of these requirements can cause denial.
- For products showing 'QL(...); SP; PA' include QL, specialty routing, and PA documentation in the submission.
- Claims lacking any required element (QL justification, PA, or SP routing) are subject to denial.
Denial risk if step‑therapy (ST) trials are not documented
When a formulary entry shows 'ST' (step therapy) the plan requires a prior trial of preferred therapy before covering the requested drug; failure to document required prior trials may result in denial.
- Bromocriptine mesylate CAPS lists 'ST' — document the required prior therapy trial on the PA.
- Some topical combination entries also show ST; include prior trial evidence where applicable.
New-Start & Initial Therapy Requirements
New start limits
New start limitations noted
Applies where the product entry explicitly states 'New starts limited to 7 day supply'.
Initial therapy notes
Some topical agents require step therapy before advanced agents.
Examples include clindamycin–tretinoin and other topical combinations listed with ST/PA.
Step Therapy Flags & Mappings
| Product | Formulary Tier | Drug Requirements / Limits |
|---|---|---|
| lisdexamfetamine dimesylate CAPS | ||
| Tier = 1B | ||
| QL( T EA daily); ST |
| Product | Formulary Tier | Drug Requirements / Limits |
|---|---|---|
| ACTEMRA SOLN 200 | ||
| Tier = 1B | ||
| Must try ibuprofen; QL(5 EA daily) |
| Product | Formulary Tier / Flag | Drug Requirements / Limits |
|---|---|---|
| vigabatrin PACK / TABS | ||
| Tier = (listed); ST/SP flag present | ||
| QL(6 EA daily); PA noted in nearby entries for similar agents |
| Product or Group | Tier Assignment | Notes |
|---|---|---|
| Various branded and combination antidiabetics (e.g., TRIJARDY XR, SYNJARDY XR) | ||
| Tiers shown (examples include Tier = 1A, 1B, 2, 3, 4) | ||
| Explicit step sequences or required prior trial failures are not provided in the excerpt |
| Product | Formulary Tier | Drug Requirements / Limits |
|---|---|---|
| amlodipine-valsartan-hydrochlorothiazide (combination) | ||
| Tier = 1B (example) | ||
| ST indicated in Drug Requirements/ILimits |
| Product | Formulary Tier / Flag | Drug Requirements / Limits |
|---|---|---|
| antiparkinson agents (example: carbidopa-levodopa formulations) | ||
| Tier = 1B (examples shown) | ||
| ST flags present for some antiparkinson agents; specific step rules not shown |
| Product | Formulary Tier / Flag | Drug Requirements / Limits |
|---|---|---|
| bromocriptine mesylate CAPS | ||
| Tier (listed) | ||
| Drug RRequirements/ILimits = ST |
| Product | Designation | Drug Requirements / Limits |
|---|---|---|
| treprostinil SOLN IJ | ||
| Tier = 4; SP indicated | ||
| ILimits = SP; PA |
| Topical Product | Formulary Tier / Designation | Drug Requirements / Limits |
|---|---|---|
| clindamycin phosphate (topical) FOAM / GEL / LOTN | ||
| Tier = 1B | ||
| AL(At least 12 yrs old); some forms list PA; QL values shown (e.g., QL( GM daily); QL(8 ML daily)) |
| Topical Product | Formulary Tier / Flag | Drug Requirements / Limits |
|---|---|---|
| amcinonide (cream/lotn/oint) | ||
| Tier = 1B (examples) | ||
| ILimits include ST and QL (e.g., QL(60 GM per fill retail)); PA noted for some topical entries |
| Product / Mapping | prug Name (Preferred alternative) | Implication |
|---|---|---|
| fluticasone propionate CREA 0.05% | ||
| prug Name = triamcinolone acetonide OINT 0.5% | ||
| Indicates a preferred alternative mapping; may imply trial of preferred product/class before non-preferred coverage |
| Product | Designation | Drug Requirements / Limits |
|---|---|---|
| pamidronate disodium SOLN 30 MG/10ML | ||
| Designation = SP; PA | ||
| ILimits = SP; PA (specialty + prior authorization required) |
Quantity Limits (QL) — Examples by Product
Specialty Pharmacy, Infusion & Site Requirements
Route SP‑designated drugs through Ambetter specialty/hemophilia pharmacies
Specialty drugs listed with 'SP' often require fulfillment at a pharmacy within Ambetter’s specialty or hemophilia network; providers must arrange dispensing through the required specialty network when SP is indicated.
- Confirm specialty pharmacy network routing when SP is shown
- Coordinate PA and specialty fulfillment to avoid delays
Secure PA and coordinate infusion/Specialty handling for IV/infusion agents
IV/infusion oncology and select infusion agents flagged with PA/SP (e.g., treprostinil SOLN IJ, TYVASO kits) imply infusion‑center handling; providers should secure PA and schedule fulfillment at an appropriate infusion site or specialty pharmacy as required.
- Obtain PA and confirm SP handling or infusion‑center scheduling for IV/infusion agents
- Include QL and kit information (e.g., TYVASO QL(3 EA daily)) in the PA
Biosimilar & Reference Product Notes
Include QL/package and PA when requesting adalimumab/biosimilar coverage
Adalimumab reference and biosimilar presentations are listed with QL and PA indicators and package limits per 180 days; providers must include the adalimumab presentation, package/QL details, and PA request when seeking coverage.
- Include package(s) per 180 day(s) and QL values (e.g., QL(0.143 EA daily)) in the PA
- Obtain PA prior to dispensing adalimumab reference or biosimilar presentations
Abbreviations & Terms
Policy Background & Scope
Background: The formulary lists FDA‑approved brand and generic medications covered under the prescription drug benefit. Generics are presented as first‑line options when available; preferred brand drugs are identified (e.g., Tier 2) when a generic is not suitable.
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