CurrentCentenePolicy N/A

Ambetter Health Formulary (Prescription Drug List) — Coverage Criteria

Defines the Ambetter Health prescription drug formulary, tier structure, and coverage controls (prior authorization, step therapy, quantity/age limits) that govern pharmacy benefits for members covered by this plan.

Policy Summary

PayerCentene

PolicyAmbetter Health Formulary (Prescription Drug List) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionProviders must submit a Prior Authorization form when PA is indicated; urgent requests responded to within 24 hours and non-urgent within 72 hours.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Tier 0–4Formulary copay tiers defined

7-dayOpioid new-start limits

Tier 4Specialty tier

24/72 hrsPA response timelines

QL / ALQuantity/Age limits noted

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Formulary coverage rules

Formulary coverage and tiering

Formulary tiering and preferred agents: Preferred generics are first-line; preferred brand drugs are listed on Tier 2 when generics are unsuitable; specialty drugs are Tier 4 and may require specialty pharmacy fulfillment.

See Formulary and Drug List Key

Coverage controls: Products may be subject to utilization controls including prior authorization (PA), step therapy (ST), quantity limits (QL), age limits (AL), or be non‑formulary (NF) requiring an exception.

Abbreviations and meanings defined in formulary key

Opioid supply restrictions

Opioid prescribing limits for new starts

Opioid new-start quantity limits: New therapy starts for opioid products are limited to a 7‑day supply. The formulary permits up to two 7‑day fills during any 28‑day period and up to a total of 28 non‑consecutive days of opioid supply within any 90‑day period; fills beyond these limits require prior authorization.two 7-day fills per 28 days; up to 28 non-consecutive days per 90 days

Applies cumulatively to all opioid medications

Starter kit/package limits

Coverage for CYLTEZO/HUMIRA starter kits and similar specialty starter kits is limited by package and per-180-day fills

Starter kit/package limits: Starter kits (e.g., CYLTEZO, HUMIRA pediatric starter kits) are subject to package limits and maximum fills over a 180‑day period (for example: package(s) per 180 day(s) retail/mail; max fill(s) per 180 day(s)) and often require prior authorization.package(s) per 180 day(s); max fill(s) per 180 day(s)

Requests exceeding these package or max‑fill limits may be denied

New start supply limits

Analgesic and nonnarcotic entries include new-start supply limits

Butalbital and select analgesics new start limit: Several butalbital-containing analgesics and certain aspirin products are designated 'New starts limited to 7 day supply'; quantity limits (e.g., QL(6 EA daily), QL(4 EA daily)) also apply per product.7 day supply for new starts

Applies where 'New starts limited to 7 day supply' is present

General coverage conditions

Coverage includes product-specific tier assignment and utilization limits; many oral opioid products are covered with restrictions when ALL of the following apply:

Common formulary conditions: Product is listed with a formulary tier; if labeled 'New starts limited to 7 day supply' the initial dispense is limited to 7 days; if a QL (quantity limit) is present the specified QL applies; if 'PA' is present prior authorization must be obtained prior to coverage.see individual QL/AL/PA entries

Operational controls (QL/AL/PA/ST) govern coverage and dispensing

General formulary coverage rules (partial)

Coverage indicated with tier assignments and utilization controls

Formulary entry: Drugs are assigned a formulary tier and may have associated utilization controls such as quantity limits (QL) and prior authorization (PA); these controls determine coverage and required documentation.

This extract lists tier/QL/PA flags but does not include clinical diagnosis criteria within the lines cited

Formulary coverage with PA/SP/QL flags

Formulary coverage entries with utilization controls

Formulary entries: Each listed drug has a tier assignment and may be subject to PA (prior authorization), SP (specialty pharmacy), and QL (quantity limits). Coverage is governed by those flags; providers must obtain PA or use SP when indicated.

Specialty and PA flags commonly apply to oncology and specialty injectables in this segment

Formulary tiering and utilization management

Coverage is inferred by formulary tier and utilization management flags

Tiering and utilization: Formulary tier (e.g., Tier 1B, Tier 3, Tier 4) combined with ILimits indicators (QL, PA, SP) defines coverage conditions and dispensing channel; specific clinical medical‑necessity criteria are not detailed in this excerpt.

See tier definitions and ILimits entries

Covered with conditions

Formulary coverage with utilization management controls

General formulary rules: Topical dermatologic agents are covered on specified tiers with common age limits (e.g., AL(At least 12 yrs old)) and quantity limits (QL); some topical products additionally require prior authorization or step therapy.see AL and QL per product

Examples include clindamycin/benzoyl peroxide combinations (AL >=12; PA; QL specified)

The formulary is a curated Prescription Drug List and is not a complete list of all covered products. Not all dosage forms or strengths may be covered, and the list is periodically reviewed and updated. Specific benefit plan designs may further exclude products or categories regardless of their appearance in this document; providers should verify member benefits and cost-sharing prior to dispensing.

Within the extract there are no explicit clinical exclusions stated (e.g., blanket statements that particular diagnoses or patient groups are excluded). The entries shown instead apply utilization controls such as Prior Authorization (PA), Quantity Limits (QL), Age Limits (AL), and occasional Step Therapy (ST) requirements to govern coverage and dispensing.

Some line items are placed on higher formulary tiers (for example, SUBSYS LIQD 800 MCG listed with Tier = 3 in the extract). Higher-tier placement typically indicates lower formulary preference and may result in increased member cost-sharing or additional utilization management before coverage.

Certain antimalarial and related products are explicitly annotated as “Covered for malaria treatment only” and include restrictive fill limits (examples in the extract show Limit 1 fill every 180 days and package/mail QL values such as QL(24 EA per fill mail)). These entries should be considered treatment‑specific with limited repeat fills.

The formulary flags some uses as requiring authorization when they are outside FDA‑approved indications. For example, certain scabicides/pediculicides (permethrin) list “Non‑FDA approved uses require Prior Authorization”. Requests for non‑FDA uses may be denied without an approved PA.

Formulary Flags, Codes and Quantity/Age Notations

Formulary flags and requirementsmixed

QL	Quantity Limit indicator used throughout drug listing
AL	Age Limit indicator used throughout drug listing
PA	Prior Authorization indicator used throughout drug listing
ST	Step Therapy indicator used throughout drug listing

Formulary quantity/age/prior auth notationsmixed

QL(2 EA daily)	Example quantity limit
QL(280 ML per 56 day(s) retail)	Quantity limit for tobramycin NEBU (example)
AL(At least 6 yrs old)	Age limit example
QL(3.6 ML per 28 day(s) retail)	Quantity limit example for injectables

Package / max fill limitsmixed

package(s) per 180 day(s) retail	Package-based limit over 180 days
max fill(s) per 180 day(s)	Maximum fills per 180-day period

Formulary utilization and authorization codesmixed

QL(6 EA daily)	Quantity limit 6 each daily
QL(4 EA daily)	Quantity limit 4 each daily
QL(100 ML daily)	Quantity limit 100 mL daily
QL(2 EA daily)	Quantity limit 2 each daily
QL(8 EA daily)	Quantity limit 8 each daily
QL(12 EA daily)	Quantity limit 12 each daily
AL(At least 45 yrs old Up to 79yrs old)	Age limit applied to aspirin chew
PA	Prior authorization required

Selected product strengths listedmixed

150 MG/3ML	amiodarone hcl SOLN 150 MG/3ML (as listed)
300 MG/3ML	enoxaparin sodium SOLN IJ 300 MG/3ML (as listed)
5000 UNIT/ML, 10000 UNIT/ML, 20000 UNIT/ML	heparin sodium (porcine) SOLN IJ concentrations (as listed)

Formulary listed products (sample)mixed

VALTOCO 20 MG	VALTOCO 20 MG DOSE LQPK 10 MG/O.1ML
VALTOCO 5 MG	VALTOCO 5 MG DOSE LIQD
dabigatran etexilate mesylate CAPS	dabigatran etexilate mesylate CAPS

Anticonvulsantsmixed

lacosamide SOLN IV 200	lacosamide SOLN IV 200
APTIOM 200 MG, 400 MG, 600 MG, 800 MG	lacosamide TABS (APTIOM)
BANZEL TABS 200 MG	rufinamide
BRIVIACT SOLN PO 10 MG/ML	BRIVIACT solution

Miscellaneous CNS and diabetes drugsmixed

topiramate TABS 200 MG	topiramate TABS 200 MG
TRINTELLIX	TRINTELLIX
JANUMET XR TB24 1000 MG-100 MG	JANUMET XR

Opioid antagonists / related productsmixedCovered

naloxone hcl LIQD	naloxone liquid formulations listed with ILimits and tier
naloxone hcl SOLN 0.4 MG/ML, 4 MG/10ML	naloxone solution formulations
naltrexone hcl	naltrexone listed (Tier = 1B)

Insulins and diabetes productsmixedCovered

APIDRA SOLOSTAR SOPN	APIDRA SOLOSTAR insulin pen (PA indicated)
HUMULIN R U-500 (CONCENTRATED) SOLN SC	Concentrated insulin with QL limits
INSULIN ASPART FLEXPEN SOPN	Insulin aspart pen

AntifungalsmixedCovered

fluconazole TABS	fluconazole tablets
posaconazole SUSP	posaconazole suspension (Tier = 3)
voriconazole TABS	voriconazole tablets

Antiemetics / 5-HT3 antagonistsmixedCovered

granisetron hcl SOLN IV 1 MG/ML	granisetron IV solution
ondansetron hcl SOLN IJ 4 MG/2 ML	ondansetron injectable solution
ondansetron hcl TABS 24 MG	ondansetron tablets 24 mg

Quantity limit expressions from formularymixed

QL(1 EA daily)	Quantity limit example shown in multiple entries
QL(2 EA daily)	Quantity limit example shown in multiple entries
QL(4 EA daily)	Quantity limit example shown in multiple entries

No CPT/HCPCS/ICD-10/NDC codes presentmixed

No codes listed

No procedure/diagnosis codes present in this excerptmixed

No codes listed

Listed product names (not CPT/HCPCS)mixed

NOVAREL IM 10000 UNIT	product line as printed
EGRIFTA SV	product line as printed
GENOTROPIN MINIQUICK PRSY	product line as printed
NORDITROPIN FLEXPRO SOPN 30 MGI3ML	product line as printed

inv-41: Opioid new-start supply limits

Opioid new-start supply policyUp to two 7-day fills during any 28-day period; up to 28 non-consecutive days in any 90-day period

Applies toAll opioid medications filled — limit applies cumulatively across opioids

Exceeding the limitFills exceeding these limits require submission of a Prior Authorization request

inv-42: New starts supply limit

New-start opioid supply limitInitial prescriptions for specified opioids are limited to a 7-day supply for new therapy starts

Context examplesLanguage 'New starts limited to 7 day supply' appears on multiple analgesic and opioid line items

DocumentationPrescribers should document indication and intended short supply when requesting fills exceeding the new-start limit

inv-46: Naloxone retail fills

Naloxone retail quantity limitQL(2 EA per retail)

Max fills per period2 max fill(s) per 30 day(s) retail

ImplicationExceeding QL or max fills may trigger denial or require PA

inv-47: Insulin QL examples

HUMULIN R U-500 exampleQL(1.34 ML daily)

Other insulin QL examplesQL(4 EA daily); QL(2 EA daily) — quantity limits vary by insulin product presentation

Follow line-item QLApply the specific QL shown for each insulin product as listed on the formulary

Prior Authorization, Step Therapy and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required for many drugs listed on the formulary. Providers must submit a completed Prior Authorization form with all supporting clinical documentation. Urgent requests will be responded to within 24 hours of receipt of all necessary information; non‑urgent requests will be responded to within 72 hours unless state law requires a faster response. If a request is disapproved or incomplete, the notice will explain the specific reasons for denial or identify missing information needed to complete the request.

PA applies to non‑formulary drugs and to formulary products specifically indicated with 'PA' in the formulary ILimits/Drug Requirements field.
Some products also require specialty pharmacy (SP) handling or are flagged as SP; PA must be obtained when SP is indicated.
Formulary abbreviation reminders: PA = Prior Authorization; QL = Quantity Limit; ST = Step Therapy; NF = Non‑formulary; SP = Specialty Drug; AL = Age Limit; SF = Split Fill.

Denial Risk

Quantity Limits, Packaging and Denial Risk

Prior authorization and quantity/packaging limits interact: requests that exceed posted quantity limits (QL), package limits (for example, packages per 180 days), or max fills per period will require documentation and may be denied without prior approval. For biologics, specialty agents, and starter kits the formulary often lists package or max‑fill restrictions that trigger PA and additional documentation requirements.

Requests exceeding QL or package(s) per X days require justification and supporting clinical documentation; exceedances may be denied if not justified.
Starter kits and multi‑package products (e.g., certain biologic starter packs) include package limits per 180 days — submit documentation when requesting exceptions.
New starts on select opioids and other controlled substances are limited (for example, new starts limited to 7 days supply); requests for larger or continuation supplies require PA and quantity justification.

Documentation Required

Documentation Requirements for PA/SP

When PA or SP is indicated on the formulary line, providers must include specialty documentation (when applicable) and follow the formulary entry notes. Documentation should include diagnosis, prior therapies (including dates and outcomes), age if an age limit (AL) applies, dosing, quantity requested and rationale for requests exceeding QL or 'new start' limits.

Include age and quantity justification when AL or QL are present on the formulary line.
For PA requests on specialty biologics or oncology agents (lines flagged SP; PA) include relevant specialty documentation: indication, prior treatments, weight when dose is weight‑based, and prior authorization history.
For non‑FDA uses flagged on the formulary (notes indicating 'approved uses require Prior Authorization' or 'Non‑FDA approved uses require Prior Authorization') attach supporting clinical rationale and literature as appropriate.

Step Therapy

Step Therapy Requirements

Step therapy (ST) requirements are present for select agents. If a formulary entry lists ST or a specific required trial (for example, 'Must try ibuprofen; ST'), the prerequisite therapy must be documented before PA will be approved unless an exemption criterion is met.

Step therapy flags appear on anticonvulsants, topical agents, and some biologic entries — document trials of required agents with dates and outcomes.
Failure to meet step therapy requirements may result in denial; appeals should include rationale for bypassing the step (e.g., intolerance, contraindication).
Some entries list ST but no algorithm in the excerpt — follow the payer's step therapy guidance or prior authorization instructions when submitting requests.

Billing Rule

Follow Formulary Limits and Channel Requirements

Follow the formulary entry notes (QL / PA / SP / ST / AL) shown on each line when submitting claims or PA requests. Items marked PA or SP; PA require prior authorization and/or specialty channel enrollment prior to dispensing and may be denied if those requirements are not met.

Line‑level indicators: PA = prior authorization required; QL = quantity limit applies; SP = specialty pharmacy requirement; ST = step therapy; AL = age limit.
Claims submitted without required PA or through non‑specialty channels when SP is indicated may be denied or delayed.
When both SP and PA are listed, ensure enrollment with the specialty pharmacy and obtain PA documentation prior to dispensing.

Step Therapy Applications

Step therapy context	Examples / Notes	Coverage label
Step therapy (ST) may require a member to try specified lower‑tier or preferred agents before coverage of alternative products is allowed.	Applied to certain stimulant/anorexiant and ADHD agents (examples include lisdexamfetamine dimesylate listed with 'QL(1 EA daily); ST' and other amphetamine/dextroamphetamine entries showing ST/QL), indicating a prerequisite trial of preferred agents may be required.
Formulary entries show ST flags alongside QL and PA; providers should document prior trials when ST is indicated.	Examples: lisdexamfetamine dimesylate CAPS — 'QL(1 EA daily); ST'; amphetamine/amphetamine combinations show QL and PA annotations that may imply step requirements.
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Product	Step requirement	Coverage label
ACTEMRA SOLN 80 MG/1ML	'Must try ibuprofen; ST' — documentation of prior trial of ibuprofen is required before ACTEMRA SOLN 80 MG/1ML is covered.
ACTEMRA SOLN (other strengths)	Line entries for ACTEMRA solutions also list QL(20 mL per 28 days) or QL(40 mL per 28 days) and specialty pharmacy (SP) for some presentations; the 80 mg/1 mL strength explicitly requires trying ibuprofen first.

Drug / class	ST indicator in listing	Coverage label
APTIOM (lacosamide) 200–800 mg	ILimits = QL(2 EA daily); ST — step therapy flag present for some APTIOM entries.
Eslicarbazepine acetate (various)	ILimits = QL(2 EA daily); ST — indicates step therapy may be required for certain strengths/forms.
Other anticonvulsants (lacosamide IV, rufinamide/BANZEL)	Multiple anticonvulsant entries include QL and some include ST or PA flags, suggesting step edits or prior authorization may apply depending on product.

Implication	Evidence from formulary	Coverage label
Tier-based placement implies preferred agents may be required prior to coverage of higher-tier products.	Several branded or combination products are listed at higher tiers (Tier = 2 or 3) and some ILimits include 'ST', indicating tier-preferred agents could be step requirements though explicit fail-first sequences are not provided.
No explicit step-failure rules in extract	The document states 'No explicit step therapy sequences are provided in this excerpt' — tiering suggests implication but not formalized algorithms.

Item / category	SP / PA notation shown	Coverage label
Select high-tier oncology and anti-infective agents (examples: fludarabine, gemcitabine entries)	Many antineoplastic entries include 'SP; PA' or 'PA' indicating specialty pharmacy routing and prior authorization are required.
ACTEMRA SOLN presentations	Some ACTEMRA listings note SP and QL values for specific strengths, consistent with specialty handling for certain presentations.

Topical product	ST noted / ILimits	Coverage label
Clindamycin phosphate‑tretinoin combinations	ILimits = AL(At least 12 yrs old); ST — step therapy specified for selected topical combination products.
Clindamycin phosphate‑benzoyl peroxide (various)	ILimits include AL(At least 12 yrs old); PA; QL(15 GM per 30 days) — some formulations have ST noted in adjacent topical entries.
Tretinoin formulations	Multiple tretinoin entries list QL values and some list ST where step therapy applies for topical retinoid combinations.

Topical formulation	ST / ILimits	Coverage label
Clobetasol propionate FOAM	ILimits = QL(3 GM daily); ST — clobetasol foam is explicitly listed with a step therapy requirement.
Clobetasol gel/ointment/solution	Various clobetasol formulations include QL and ST or PA flags (e.g., QL(2 GM daily); ST or QL(1 GM daily); PA) depending on formulation.

Diuretic / related product	SP / ST / ILimits noted	Coverage label
Bumetanide SOLN 0.25	ILimits = QL(0.143 EA daily); PA — listed with QL and PA; some presentations reference SP indicating specialty routing for certain forms.
Bumetanide TABS	ILimits = QL(5 EA daily); some bumetanide tablet entries include SP; PA indicating step or specialty requirements per line-item.
Furosemide, torsemide, spironolactone, triamterene & HCTZ	Several diuretics are shown with 'SP; PA' or ILimits that reference ST or specialty handling (e.g., furosemide SOLN PO listed with SP; PA; triamterene CAPS with QL).

Quantity Limits, Age Limits and Fill Restrictions

inv-166: Stimulants and related QLs

Common stimulant QLsExamples include QL(1 EA daily), QL(2 EA daily), QL(4 EA daily)

Large-volume nebulized exampleQL(280 ML per 56 day(s) retail; 280 ML per 56 days mail)

Daily-limit patternMany stimulant/related agents use EA-per-day QL expressions (apply per line item)

Variation by strength/formSpecific QL varies by product strength and dosage form — use the line-item QL

inv-167: Opioids (new starts)

Opioid new-start rules (summary)Allow up to two 7-day fills during any 28-day period; up to 28 nonconsecutive days in any 90-day period

Applies toAll opioid medications identified with 'New starts limited to 7 day supply'

Authorization for excessPrior Authorization required for fills exceeding these limits

inv-170: CYLTEZO / HUMIRA starter kits

Starter kit/package limitPackage(s) per 180 day(s) retail/mail (starter kits limited to specified packages per 180 days)

Examples of QL in kitsSpecific presentations list QL values (e.g., QL(0.215 EA daily) for certain CYLTEZO presentations)

AuthorizationThese starter kits often require Prior Authorization (PA) per line-item

inv-171: ACTEMRA SOLN quantity limits

ACTEMRA SOLN quantity limitsQL(40 ML per 28 day(s) retail/mail) and QL(20 ML per 28 day(s)) depending on strength

80 mg/1 mL strength noteACTEMRA SOLN 80 MG/1ML entries include QL(20 ML per 28 day(s)) and may note 'Must try ibuprofen; ST'

Specialty routingSome ACTEMRA presentations are noted SP and may require specialty pharmacy handling and PA

inv-172: Butalbital/aspirin new-start limits and QLs

New-start limit for butalbital/aspirin entriesNew starts limited to 7 day supply (applies to several butalbital and aspirin line items)

Quantity limit examplesQL(6 EA daily); QL(4 EA daily) shown for various formulations

Prior Authorization flagSome line items also include PA — follow line-item requirements

inv-173: Multiple product QL examples

Multiple product QL examplesVaries by product; examples include QL(6 EA daily); QL(4 EA daily); QL(100 ML daily); QL(8 EA daily); QL(12 EA daily)

Apply per line itemEach product listing specifies the applicable QL — use the exact line-item value

Dose/strength dependentQLs differ by strength, form, and therapeutic class

inv-183: Naloxone QL and max fills

Naloxone QL per retailQL(2 EA per retail)

Max fills per 30 days (retail)2 max fill(s) per 30 day(s) retail

Denial riskExceeding these limits may trigger denial or require PA

inv-184: HUMULIN R U-500 QL example

HUMULIN R U-500 QL exampleQL(1.34 ML daily)

Product-class noteConcentrated insulins list product-specific ML/day QLs in formulary entries

Follow line-item ILimitsUse the exact ILimits shown for the specific insulin presentation

inv-192: Malaria product limits

Malaria product fill limitLimit 1 fill every 180 days

Mail fill QL exampleQL(24 EA per fill mail)

Covered useSome malaria products are listed 'Covered for malaria treatment only' with these fill limits

inv-201: STELARA specialty injectable limits

STELARA mail QLQL(60 GM per fill mail)

Retail max fill1 max fill(s) per 30 day(s) retail

Specialty/PA noteSTELARA entries include ILimits and may require PA/SP handling

inv-204: DUPIXENT fill/QL example

DUPIXENT QL exampleQL(0.082 ML daily)

Fill frequency limitsMax fill(s) per 30 day(s) retail; mail fill limits specified per presentation

PA requiredDUPIXENT line items include PA in ILimits

inv-205: TRUE METRIX test strips QL

TRUE METRIX test strips QLQL(3.34 EA daily)

OTC/Rx noteTRUE METRIX listed with RX/OTC designation in ILimits

Apply per-day QLLimit expressed as EA per day — follow line-item limit

inv-206: triamterene & hydrochlorothiazide QL example

Triamterene & HCTZ QL exampleQL(0.143 EA daily)

Formulation noteQL differs between capsule and tablet listings — check line-item

Apply daily QLLimit expressed as EA per day

inv-209: hydrochlorothiazide QL example

Hydrochlorothiazide QL exampleQL(2 EA daily)

Strength rangeApplies to HCTZ 12.5–50 mg line items as shown

Follow specific ILimitsUse the exact QL on the formulary line-item for dispensing limits

inv-210: metoclopramide QL example

Metoclopramide solution QLQL(60 ML daily)

Formulation-specificApplies to metoclopramide HCl solution oral presentations as listed

Provider documentationPrescribers should document indication when requesting quantities exceeding QL

inv-211: mesalamine QL example

Mesalamine TBEC QLQL(6 EA daily)

Product formSpecifically shown for mesalamine TBEC 800 mg line-item

Apply per-day limitLimit expressed as EA per day — follow line-item QL

Abbreviations and Definitions

inv-116: Formulary / Prescription Drug List

DefinitionFormulary / Prescription Drug List: A list of FDA‑approved brand and generic drugs covered under the prescription benefit; not exhaustive and subject to periodic updates.

PurposeIdentifies covered drugs, tier placement, and associated utilization controls (QL, PA, ST, AL)

Coverage noteNot all dosage forms or strengths may be covered; check the benefit plan for limitations

inv-117: Abbreviations (AL, QL, PA, ST, NF, RX/OTC, SP, SF)

ALAge Limit — indicates coverage only for specified ages (e.g., AL(At least 12 yrs old)).

QLQuantity Limit — maximum allowed quantity per time period as presented in formulary entries (e.g., QL(2 EA daily)).

PAPrior Authorization — requires provider to obtain approval before coverage when indicated (noted as 'PA').

STStep Therapy — requires trial of specified lower-step drug(s) before coverage of another agent (noted as 'ST').

NFNon‑formulary — product not covered unless an exception is granted

RX/OTCPrescription and Over‑the‑Counter designation — indicates both forms may exist

SPSpecialty Drug — may require specialty pharmacy routing and handling

inv-118: QL

QL (Quantity Limit) definitionQuantity Limit as presented in formulary entries (e.g., QL(2 EA daily); QL(280 ML per 56 day(s))).

Unit formatsQL expressions use units such as EA (each), ML (milliliter), GM (gram), or per-fill and per-period formats

PurposeSpecifies maximum quantity allowed per day, per fill, or per period — exceeding QL may require PA or be denied

inv-119: AL

AL (Age Limit) definitionAge Limit as presented in formulary entries (e.g., AL(At least 6 yrs old); AL(At least 12 yrs old)).

ApplicationSpecifies minimum and/or maximum ages for coverage of a product or formulation

DocumentationAge may need to be documented when requesting PA or override of an AL

inv-121: New starts limited to 7 day supply

Definition - New starts limited to 7 day supplyA formulary restriction that limits the initial prescription of certain opioid products to a maximum 7‑day supply for new therapy starts

ScopeApplied to many oral opioid and select analgesic line items as noted on the formulary

Exceeding the limitFills beyond the new‑start 7‑day supply require submission of a Prior Authorization request

inv-128: Tier

TierFormulary tier designation indicating coverage level or member cost‑sharing category (e.g., Tier 0–4); Tier 4 is specialty with highest copayment

UseTier guides member cost-sharing and may influence step therapy or preferred agents

Specialty tier noteSpecialty (Tier 4) products may require fulfillment at specialty pharmacies

inv-133: PA

PA (Prior Authorization)Prior Authorization indicates the provider must obtain approval before coverage when 'PA' appears in the formulary ILimits

When requiredMany biologics, specialty agents, and selected formulations list 'PA' — follow the line-item note

Submission timelinesUrgent PA requests are responded to within 24 hours; non‑urgent within 72 hours unless state law requires faster response

inv-137: Specialty Pharmacy

Specialty Pharmacy (SP)SP indicates specialty pharmacy routing requirement; specialty drugs may require fulfillment at participating specialty/hemophilia network pharmacies

When appliedUsed for many injectable, biologic, and complex therapies listed on the formulary

PA often accompanies SPSP entries commonly appear with PA — providers should confirm specialty channel and authorization requirements

inv-142: AL example

AL exampleAL(At least 12 yrs old) — example age‑limit notation used in topical dermatologic entries

UsageAL expressions specify minimum (and sometimes maximum) ages for coverage

Check line itemApply the specific AL shown on the formulary line for the product and formulation

OpenPayer

Ambetter Health Formulary (Prescription Drug List) — Coverage Criteria

Formulary Coverage Criteria

Formulary Flags, Codes and Quantity/Age Notations

Prior Authorization, Step Therapy and Documentation Requirements

Initial Therapy and Site-of-Care Considerations

Step Therapy Applications

Quantity Limits, Age Limits and Fill Restrictions

Abbreviations and Definitions

Specialty Pharmacy and Fulfillment Requirements

Background and Scope

Policy Revision History