Ambetter Health Formulary (Prescription Drug List) — Coverage Criteria
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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.
No material clinical or coverage changes in this revision.
Formulary Coverage Criteria
Formulary coverage rules
Formulary coverage and tiering
See Formulary and Drug List Key
Abbreviations and meanings defined in formulary key
Opioid supply restrictions
Opioid prescribing limits for new starts
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
Requests exceeding these package or max‑fill limits may be denied
New start supply limits
Analgesic and nonnarcotic entries include new-start supply limits
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:
Operational controls (QL/AL/PA/ST) govern coverage and dispensing
General formulary coverage rules (partial)
Coverage indicated with tier assignments and utilization controls
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
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
See tier definitions and ILimits entries
Covered with conditions
Formulary coverage with utilization management controls
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
| 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 |
| 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(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 |
| 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 |
| 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) |
| 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 |
| 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 |
| topiramate TABS 200 MG | topiramate TABS 200 MG |
| TRINTELLIX | TRINTELLIX |
| JANUMET XR TB24 1000 MG-100 MG | JANUMET XR |
| 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) |
| 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 |
| fluconazole TABS | fluconazole tablets |
| posaconazole SUSP | posaconazole suspension (Tier = 3) |
| voriconazole TABS | voriconazole tablets |
| 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 |
| 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 codes listed |
| No codes listed |
| 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 |
Prior Authorization, Step Therapy and Documentation Requirements
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.
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 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 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.
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.
Initial Therapy and Site-of-Care Considerations
Initial therapy restrictions
Initial prescribing restrictions seen in the extract
Applies where 'New starts limited to 7 day supply' is present; see opioid policy for cumulative limits
Initial coverage considerations for pulmonary hypertension agents
Initial coverage considerations for pulmonary hypertension agents
No specific medical‑necessity diagnostic criteria provided in this excerpt; follow PA/SP processes when indicated
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
Abbreviations and Definitions
Specialty Pharmacy and Fulfillment Requirements
Background and Scope
The formulary distinguishes preferred generics as first‑line treatment options and identifies preferred brand drugs (e.g., placed on Tier 2) when generics are unsuitable. Specialty agents are assigned top tier placement and often require specialty pharmacy handling; these products may also be subject to Prior Authorization (PA), Step Therapy (ST), or Quantity/Age Limits (QL/AL) as noted on their formulary line entries.
Policy Revision History
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