Ambetter Health Formulary (Prescription Drug List) — Coverage Criteria
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Defines the Ambetter Health prescription drug formulary, tiering, coverage designations (PA, ST, QL, NF, SP) and prior authorization/coverage processes for Ambetter prescription drug benefits.
No material clinical or coverage changes in this revision.
Formulary Coverage Rules and Criteria
Formulary coverage rules
Formulary coverage and tiering
Tier definitions described in document
Specialty network and handling described in formulary guidance
Providers must submit a PA form to request an exception
Opioid supply limits
Opioid prescribing limits for new starts
Limit applies cumulatively to all opioid prescriptions
Biologic products (adalimumab examples)
Covered when listed formularies with limits and PA are satisfied
Multiple adalimumab presentations list PA and QL
PDE4 inhibitors and selected oral agents
Covered when PA and quantity/age rules satisfied
Age and package limits apply as shown on product lines
Opioid and analgesic product coverage
Covered with formulary-specific limits and prior authorization where indicated.
Adherence to per‑product ILimits and PA required for coverage
Formulary tiering and administrative conditions
Formulary coverage is expressed via tier assignments and administrative flags; coverage is contingent on plan tier and any PA/SP requirements.
Tier definitions and examples are provided in the formulary key
PA/ST/SP/QL appear on product ILimits fields throughout the listing
Product-level coverage controls
Coverage listed per product line with tier and ILimits; PA and QL determine access controls
This extract lists ILimits but does not include patient‑specific clinical criteria
Coverage conditions (by tier/limit flags)
Formulary coverage and limits apply as listed; coverage varies by tier and product-specific flags (PA, ST, QL).
See individual product lines for specific QL, PA, and ST values
Indication-limited antimalarial coverage
Examples of indication-limited coverage
Documentation of indication (malaria treatment) required for coverage
PA/SP managed products
Utilization management for select anti-infectives and antineoplastics
Failure to obtain required PA/SP may result in denial
Formulary tiering and utilization controls
Coverage governed by formulary tiering and utilization management flags
No explicit clinical AND/OR criteria present in this segment; adhere to ILimits and PA/SP flags
The formulary provided in this extract is a representation of Ambetter Health’s Prescription Drug List but is not a complete list of covered drugs. The document itself notes that not all dosage forms or strengths may be covered, and that specific plan benefit designs can restrict coverage even for items that appear on the formulary. Providers and billing staff should verify member-specific benefit plans for exact coverage, tier assignment, and member cost-sharing before assuming coverage.
This partial extract does not include explicit exclusion statements. The listing shows product lines, tier assignments and ILimits (e.g., QL, AL, PA) but contains no standalone exclusion language in the cited portion. Absence of exclusions in this excerpt does not imply there are none in the full policy — check the complete policy for formal exclusion rules.
In the portions of the formulary shown here there are no explicit exclusion rules stated. The extract lists product-level tiers and quantity limits (for example, several NSAID entries include QL values) but does not present named exclusion criteria within these chunks.
No explicit clinical exclusions are provided in this excerpt. The cited lines list multiple testosterone and related products with tier and ILimits information but do not define clinical exclusion criteria or specific medically ineligible conditions in the presented text.
The extract segments reviewed do not contain explicit exclusion language. Entries in this area focus on product presentations, tiers, and ILimits (e.g., PA for certain pen or penfill products) rather than naming conditions or services that are excluded from coverage.
This is a partial extract of the formulary and therefore does not list all products. The text notes that products not present in these chunks are outside the scope of the provided excerpt; reviewers should consult the full formulary for comprehensive product listings and any product‑specific coverage rules.
No explicit exclusion rules are present in the chunks cited here. The segment contains tiering, QL, PA and SP flags for drug lines (e.g., verapamil and digoxin entries) but does not state standalone exclusion provisions in this portion of the document.
For digestive enzyme products such as ZENPEP (and similarly CREON in other portions of the formulary), the extract specifies that non‑FDA approved uses require Prior Authorization (PA). Prior authorization is therefore required to cover off‑label or non‑FDA indications for these enzyme products.
The partial extract does not include statements declaring items as 'not medically necessary.' The cited lines contain tier, ILimits and PA flags for listed products but no explicit 'not medically necessary' determinations in this excerpt.
The portions of the document shown here do not contain any explicit 'not medically necessary' language. Product entries in this area focus on quantity limits and tiering without issuing formal non‑coverage declarations for specific clinical scenarios.
No 'not medically necessary' findings are present in the provided excerpt. The content in these chunks addresses formulary structure (tiers, ILimits) and product entries rather than formal determinations of medical necessity.
This extract does not state any 'not medically necessary' conditions. The referenced material lists products, associated ILimits and PA indicators but does not include explicit NMN rulings in the visible segments.
No explicit 'not medically necessary' statements are present in these chunks. The anti‑infective and related entries specify QL per fill and tiering, but do not contain stated NMN determinations in the excerpt.
This item is an unspecified summary fallback present in the inventory with no content provided in the extract. Refer to the complete formulary for any missing summary or policy statement related to this inventory line.
Formulary Modifiers, Limits, and Coding Examples
| QL(1 EA daily) | Quantity limit examples listed for multiple products |
| AL(At least yrs old) | Age limit examples (various entries show age limit placeholders) |
| PA | Prior Authorization requirement marker |
| ST | Step therapy requirement marker |
| SP | Specialty tier marker |
| QL(0.143 EA daily) | Quantity limit example shown for multiple adalimumab presentations |
| package(s) per 180 day(s) retail | Package/fill limit example |
| QL(2 EA daily) | Quantity limit example (e.g., OTEZLA tabs) |
| AL(At least 45 yrs old Up to 79yrs old) | Age limit applied to OTEZLA entries |
| No codes listed |
| QL(900 ML per 30 day(s) retail) | Quantity limit for rivaroxaban suspension (rivaroxaban SUSR 1 MG/ML) |
| QL(2 EA daily) | Quantity limit for rivaroxaban tablets 2.5 mg |
| QL(4 ML daily) | Quantity limit example (example: arformoterol tartrate) |
| QL(0.38 GM) | Quantity limit example for BREZTRI AEROSPHERE |
| QL(4 EA daily) | Quantity limit example for alprazolam 0.25-1 mg tablets |
| QL(8 ML daily) | Quantity limit example for diazepam oral solution |
| 0.4 MG/ML, 4 MG/10ML | naloxone hcl SOLN strengths referenced as product names (formatted as in document) |
| XIFAXAN 200 MG | listed with Tier = 3 and ILimits = QL(3 EA daily) |
| QL(4 EA daily; 40 EA per fill retail) | Quantity limit for minoxidil 2.5 MG, 10 MG (and other entries) |
| QL(300 ML per fill retail) | Quantity limit for unspecified anti-infective liquid |
| PA | Prior authorization required (multiple entries) |
| SP | Specialty designation (appears on several antineoplastic entries) |
| QL(12 EA per fill retail; 12 per fill mail) | Quantity limit for atovaquone-proguanil hcl |
| 1 max fill(s) per 180 day(s) retail | Fill frequency limit for malaria treatment products |
| QL(2 EA daily) | Quantity limit example for XTANDI 80 mg / other entries |
| QL(1 EA daily) | Quantity limit example |
| QL(2 EA daily) | Quantity limit example |
| QL(75 ML) | Quantity limit for HEMANGEOL SOLN PO (example line-item) |
Prior Authorization, Step Therapy, and Documentation Requirements
Prior Authorization Required
Prior Authorization Required for Non‑Formulary Drugs: Providers must complete and submit the payer's Prior Authorization form when requesting coverage for non‑formulary (NF) drugs. Urgent PA requests will be responded to within 24 hours of receipt of all necessary information; non‑urgent requests within 72 hours unless state law requires faster response. If disapproved or incomplete, the notice will explain specific reasons or identify missing information needed to complete the request.
- Submit completed Prior Authorization form and supporting clinical documentation
- Urgent requests: response within 24 hours once all information received
- Non‑urgent requests: response within 72 hours once all information received
PA and Package / Quantity Limits
PA and package/quantity limits: Many biologic and specialty products have package, fill-frequency, and quantity limits (QL) and require prior authorization. Examples include multiple adalimumab formulations with package limits per 180 days and QL entries; new starts for some injectables limited to 7‑day supplies. Exceeding QLs or not obtaining PA may result in claim denials.
- Adalimumab products: package limits and PA (example: package(s) per 180 days retail/mail; QL listed)
- Enbrel/Actemra examples: QL and new‑start 7‑day supply limits
- Document intended quantity and dosing when submitting PA to reflect package/QL requests
PA and Age Limits
PA and Age‑Limit Requirements: Several products require prior authorization and have age limits (AL). Verify patient age against the AL entry before submitting a PA; prescriptions not meeting age limits are at risk for denial.
- OTEZLA: PA required; AL entries specify age ranges (e.g., At least 45 yrs up to 79 yrs)
- Topical acne agents (benzoyl peroxide, clindamycin combinations): AL frequently specified (At least 12 yrs old)
- Include patient age in PA documentation to demonstrate compliance with AL
PA for Specific Formulations
PA Required for Selected Formulations: Specific formulations (topical foams/gels, injectables, concentrated solutions) are flagged for prior authorization. Check the formulation-level ILimits/Drug Requirements before dispensing.
- Clindamycin topical FOAM/GEL/LOTION: AL and PA indicated for some formulations
- Calcitriol and calcipotriene solutions: QL and PA indicated
- Certain inhalation/solution formulations (e.g., amiodarone 150 mg/3 mL) list PA
Products Marked PA / SP
Products Requiring Prior Authorization: Many individual agents and classes are explicitly marked PA or SP;PA in the formulary extract. Specialty (SP) and Tier‑4 products commonly require PA and may also require specialty pharmacy (SP) fulfillment.
- Antineoplastics and adjunctive therapies: multiple agents flagged SP; PA (e.g., cisplatin, busulfan, carmustine)
- Biologics and monoclonal antibodies: examples include Ruxience, Truxima, Yervoy, Arzerra marked SP; PA
- Pulmonary vasodilators and prostacyclin agents: PA and QL entries present
PA for High‑Tier and Specialty Agents
PA Required for Specified Agents and High‑Tier/Specialty Drugs: High‑tier and specialty agents (e.g., COSENTYX, REPATHA, TYVASO kits, rivaroxaban suspensions) are listed with PA and QL constraints; prescribers should request authorization and note specialty fulfillment requirements where indicated.
- REPATHA: Tier 4 with QL and PA
- COSENTYX formulations: QL and PA listed for multiple presentations
- TYVASO refill kits and starter kits: PA required
PA for Topical Products
Prior Authorization for Selected Topicals: Several topical agents require PA, have quantity or fill limits, and may include age restrictions. Confirm AL/QL and request PA when required to avoid denials.
- Clindamycin phosphate combinations (e.g., clindamycin‑benzoyl peroxide, clindamycin‑tretinoin): AL and PA may apply
- Ketoconazole, luliconazole, naftifine topical formulations: many entries show PA or QL constraints
- Topical corticosteroids and enzyme topicals (e.g., SANTYL): PA appears in ILimits
PA and Specialty Pharmacy Flags
Prior Authorization Flags and Specialty Pharmacy Indicators: Formulary entries use ILimits flags such as PA, SP, ST, AL, and QL. SP indicates specialty pharmacy/network requirements; combined SP;PA or PA without SP both require authorization prior to coverage.
- PA flag: authorization required before claim adjudication
- SP flag: specialty fulfillment — may require dispensing through designated specialty pharmacy
- Combined flags (SP;PA): both specialty distribution and authorization are required
Denial Risk — QL, PA, and Step Therapy
Denial Risk from QL, PA, and ST: Requests exceeding quantity limits, lacking required prior authorization, or not meeting step‑therapy (ST) requirements are at increased risk for denial. Prescribers should document clinical rationale, prior trials, and intended quantity to support approvals.
- Quantity limits (QL): follow per‑day, per‑fill, and per‑period QL values shown (examples: QL(0.143 EA daily); max fills per 180 days)
- Step Therapy (ST): where ST is listed, document prior trials of preferred agents (e.g., 'Must try ibuprofen' noted near Actemra)
- Incomplete PA requests: denials will identify missing material information; include dosing, duration, prior therapies, and age where applicable
Documentation to Support PA
Documentation Requirements for Prior Authorization: When requesting PA include supporting clinical documentation — diagnosis, indication, prior medication trials (for ST), dosing, intended quantity/fill frequency, and patient age when AL applies. Incomplete requests will delay review or result in denial.
- Include diagnosis and indication and confirm whether requested use is FDA‑approved or off‑label (non‑FDA uses often require PA)
- Provide prior therapy history when ST applies and dates/duration of trials
- Specify dosing, quantity requested, and package size to match formulary QL/package constraints
Quantity and Fill Limits
Quantity & Fill Limits — Operational Notes: Observe per‑day, per‑fill, and per‑period limits and report the requested quantity on the PA form. New‑start supply limits (e.g., 7‑day limits for certain injectables) and max fills per 30/90/180 days are enforced.
- New starts: examples where new starts are limited to 7‑day supply (ENBREL entries)
- Max fills: many entries list '1 max fill(s) per 180 day(s)' or similar limits — include intended refill schedule in PA
- Package limits: biologics often list 'package(s) per 180 day(s) retail/mail' — ensure request aligns with package rules
PA for Non‑FDA Uses
Non‑FDA Uses Require Prior Authorization: Digestive enzyme products (CREON, ZENPEP) and other agents list 'Non‑FDA approved uses require Prior Authorization.' For off‑label indications, include rationale and supporting literature or chart notes with the PA request.
- CREON and ZENPEP: Non‑FDA approved uses noted as requiring PA
- For off‑label use include clinical justification, prior treatments, and relevant diagnostics
Step Therapy / Trial Requirements
Step Therapy and Trial Requirements: Step therapy (ST) is applied to some drug classes and combination products. Where ST is indicated, document that required first‑line agents were tried and were ineffective, contraindicated, or not tolerated before requesting the next‑line agent.
- ST examples: 'Must try ibuprofen' near Actemra entries; topical acne product ST entries (e.g., clindamycin‑tretinoin)
- Therapeutic‑class preferences and tiering may imply preferred agents even where explicit ST sequence is not shown — include prior regimen details
Step / Age / Specialty Indicators
Step Therapy, Age‑Related and Specialty Program Indicators: Some products require both step therapy and meet age limits or specialty program requirements. Verify all applicable flags (ST, AL, SP, PA) and include evidence of meeting each criterion in the PA submission.
- OTEZLA: ST and AL present for some package forms — include age and prior trials
- Topical acne agents: ST plus AL (At least 12 yrs) — document prior topical treatments and patient age
- Specialty program indicators (SP) often accompany PA for agents used in specialized care settings
Initial Therapy Limitations and Requirements
Initial therapy limits
Initial therapy limitations present in extract
Provider should document justification on PA requests for longer initial supply
Initial coverage controls
Initial dispensing controls shown via tiers and QL
This extract does not provide patient‑specific eligibility criteria
Step therapy indicators
Some combination products are subject to step therapy or preferred first-line agents.
See specific product lines for ST flag and required prior therapy
Topical acne initial therapy constraints
Step therapy and age limits noted for topical acne agents
Examples include clindamycin phosphate combinations and DIFFERIN LOTN
Continuation Therapy and Refill Controls
Continuation therapy notes
Continuation rules observed in extract
Exact continuation criteria are not fully detailed in this partial extract
Step Therapy Sequences and Indicators
| Product | ST |
|---|---|
| lisdexamfetamine dimesylate CAPS | |
| dextroamphetamine sulfate TABS | |
| methylphenidate (various formulations) |
| Context | Requirement |
|---|---|
| Actemra SOLN 80 MG/4ML (Actemra entries) | |
| {"text":"Must try ibuprofen before coverage ("Must try ibuprofen" noted in Actemra line)","status":""} |
| Product | Prerequisite / Age Limit |
|---|---|
| OTEZLA TABS | |
| QL(2 EA daily); AL(At least 45 yrs old Up to 79yrs old); PA |
| Segment | ST requirement |
|---|---|
| Selected respiratory / cardiovascular combinations (examples) | |
| No explicit step therapy sequences listed; tiering/QL indicated rather than ST |
| Product | ST |
|---|---|
| eslicarbazepine acetate 200/400/600 MG | |
| gabapentin (selected strengths) |
| Therapeutic class / product | Preference / ST note |
|---|---|
| DPP-4 / Incretin / SGLT2 class listings (e.g., JANUMET, JARDIANCE) | |
| Class-based preferences implied; explicit step-failure rules not provided in extract |
| Combination product | ST |
|---|---|
| amlodipine-valsartan (combination) | |
| amlodipine-valsartan-hydrochlorothiazide |
| Chunk / area | Step therapy presence |
|---|---|
| Cardiac glycosides / verapamil and related entries | |
| No explicit ST rules present; tiering and PA/QL imply preference controls |
| Topical acne product | ST |
|---|---|
| clindamycin phosphate- tretinoin | |
| DIFFERIN LOTN |
| Product | Notes (QL/PA) |
|---|---|
| brimonidine tartrate (topical) | |
| QL(1 GM daily); PA noted for some formulations |
Quantity and Fill Limits by Product
Specialty Pharmacy, Infusion, and Fulfillment Requirements
Use Ambetter specialty/hemophilia network pharmacies for SP items
Specialty tier drugs may require fulfillment at pharmacies participating in Ambetter's specialty or hemophilia networks; providers should direct prescriptions to the appropriate specialty pharmacy network when 'SP' is indicated.
- When 'SP' is shown, use Ambetter specialty/hemophilia network pharmacies for dispensing
- Confirm pharmacy network participation via Ambetter's pharmacy information resources
Obtain PA and coordinate infusion‑site billing for IV products
IV products listed with PA and QL flags (e.g., QUZYTTIR SOLN IV) may require infusion‑site billing and prior authorization; providers should coordinate authorization and site‑of‑care billing prior to administration.
- Obtain PA for IV preparations before infusion
- Coordinate infusion‑site authorization and appropriate billing codes
Apply same PA and package/QL rules to SIMLANDI (adalimumab) as HUMIRA
SIMLANDI (an adalimumab product) is listed alongside HUMIRA with PA and package/QL rules; providers must follow the same PA and package/quantity limits for listed adalimumab products and biosimilars.
- Treat SIMLANDI entries like HUMIRA for PA and package/QL compliance
- Include package/QL details and obtain PA when required for adalimumab products
Abbreviations and Term Definitions
Policy Background and Scope
Background: The formulary differentiates between generic and brand products and directs that generics are preferred as first‑line treatment when available. It also indicates that specialty or high‑cost products may be managed differently (e.g., specialty fulfillment or program handling), and that tiers plus administrative flags (PA, ST, QL, SP) are used to govern access and coverage.
Biosimilar Listings and Notes
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