Ambetter Health Formulary (Prescription Drug List) — Coverage Criteria
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This document governs the Ambetter Health prescription drug formulary (covered brand and generic drugs), formulary tiers, prior authorization and quantity/age limits, and specialty drug handling for Ambetter members. It affects providers prescribing medications and pharmacies dispensing under Ambetter plans.
No material clinical or coverage changes in this revision.
Formulary Coverage Rules & Product-Level Controls
Formulary coverage rules
Covered when ALL of the following are met:
See general formulary description
See Prior Authorization for Non‑Formulary Drugs
See Opioid Medications policy
Utilization controls for specific formulations
Covered when ANY of the following utilization conditions are satisfied:
See butalbital entries
Age and quantity constraints
Covered when product-level age and quantity constraints are met:
See per‑product AL values
Varies by product; apply the exact QL shown
Formulary coverage with utilization limits
Coverage for opioid and related analgesic products is subject to the following:
Apply per listed product entries
PA/SP flagged agents
Covered when ANY of the following apply:
Examples: entries annotated SP; PA (see antineoplastic/antimalarial lines)
Quantity-limited agents
Covered when the specified quantity limits are not exceeded:
Multiple QL formats (daily, per fill, per period) appear in the formulary
Coverage contingent on PA/QL/SP
Coverage is provided when ALL drug‑specific conditions are satisfied:
Many antineoplastic and specialty agents include SP and/or PA
Formulary tier and utilization controls
Covered when ALL of the following are met:
See Tier and ILimits on each product line
Formulary tiering and utilization controls (partial)
Covered when ALL of the following product-level requirements are met:
Examples: topical agents with AL(At least 12 yrs old), QL values, or ST flags
General coverage for listed topical and related products
Covered when ALL of the following are satisfied:
Follow specific Tier/QL/PA/ST for each topical entry
The formulary is a curated prescription drug list and is not intended to be a complete listing of every covered product or every dosage form or strength. Coverage for a listed drug depends on the member's specific benefit design, the drug's listed tier, and any line-level utilization controls (for example, generics are preferred as first-line options). Providers should verify plan-specific benefit limits and any drug-specific requirements (QL, PA, AL, ST, SP) shown on the formulary prior to prescribing or dispensing.
Within this segment there are no explicit formulary exclusions listed. Drug rows in the extracted portion do not state any products as categorically excluded; however, plan-specific benefit designs may still exclude certain items despite their appearance in the document.
The partial section reviewed does not contain explicit exclusions. Entries shown include standard tiering and ILimits fields but no statements declaring a product or class to be excluded from coverage.
Some entries are labeled for limited indications; for example, certain antimalarial agents are annotated as "Covered for malaria treatment only", demonstrating indication‑limited coverage rather than broad coverage for all uses.
This document segment contains no explicit exclusions. Listed products in the excerpt show utilization controls (e.g., QL, PA, SP) but do not include statements excluding coverage outright.
In the excerpted material there are no explicit statements labeling drugs as not covered. Coverage appears contingent on meeting listed utilization controls (PA, QL, SP) rather than on categorical exclusion language.
The formulary requires prior authorization for non‑FDA approved uses of certain products. Where an entry indicates non‑FDA uses require PA, providers must obtain the PA to secure coverage for that off‑label use.
No explicit 'Not Medically Necessary' (NMN) statements are present in this segment of the formulary extract.
This partial section contains no explicit 'not medically necessary' determinations; coverage references are tied to tiering and utilization controls rather than NMN language.
No NMN statements are visible in the reviewed excerpt; product coverage in this area is expressed via tiers and ILimits (QL, PA) rather than explicit NMN language.
When a product is used for indications that are not FDA‑approved, the formulary notes that such uses require prior authorization; absent PA, those non‑FDA uses are flagged and may be treated as not covered unless authorized.
Codes, Abbreviations, and Quantity Examples
| PA | Prior Authorization |
| QL | Quantity Limit |
| AL | Age Limit |
| ST | Step Therapy |
| NF | Non-formulary |
| SP | Specialty |
| SF | Split Fill |
| No codes listed |
| No codes listed |
| No codes listed |
| XIFAXAN 200 MG | listed as a 'prug Name' in several entries |
| ALINIA SUSR | listed as a 'prug Name' for valsartan-hydrochlorothiazide entry |
| VECAMYL | listed as drug name with ILimits = PA |
| MVASI | prug Name for fludarabine phosphate SOLN |
| ZIRABEV | prug Name for SOLN fludarabine phosphate |
| LOQTORZI | prug Name for gemcitabine hcl SOLR |
| 240 MG | FIRMAGON (240 MG DOSE) - quantity limit noted as QL(0.143 EA daily); SP; PA |
| 3.5 MG | BORTEZOMIB SOLR IV 3.5 MG - listed with QL references |
| QL(8 EA daily) | Quantity limit for INTELENCE 25 MG |
| QL(2 EA daily) | Quantity limit for ISENTRESS HD TABS / ISENTRESS TABS |
| QL(6 EA daily) | Quantity limit for ISENTRESS CHEW |
| QL(12.5 ML) | Quantity limit for KALETRA SOLN |
| QL(30 ML) | Quantity limit for lamivudine SOLN |
| PA | Prior authorization required |
| SP | Specialty Pharmacy |
| QL(3.34 EA daily) | Quantity limit example for TRUE METRIX / test strips as listed |
| QL(6 EA daily) | Quantity limit example for PRECISION XTRA KETONE listed |
| QL(4 EA daily) | Quantity limit example for KETOSTIX STRP |
Prior Authorization, Step Therapy, and Documentation Requirements
Prior Authorization Required
Prior authorization (PA) is required for many listed products and selected agents across the formulary. Claims for drugs requiring PA may be denied at point-of-sale or on claim adjudication if PA is not obtained.
- PA required for many antineoplastics and other high‑tier oncology agents (SP; PA).
- PA indicated for selected specialty and high‑tier products (examples: injectable biologics, enzyme therapies, orphan drugs).
- PA required for select pulmonary hypertension agents (e.g., ambrisentan, bosentan, tadalafil, sildenafil, UPTRAVI, TYVASO) and other specialty pulmonary products.
- Certain topical and non‑FDA uses require PA; non‑FDA approved uses may be denied without prior authorization.
Documentation and Quantity/Age Requirements
Prior authorization requests must include documentation that supports medical necessity and adherence to quantity limits (QL) and age limits (AL) where applicable. Examples of required documentation include diagnosis, prior therapies tried (for ST requirements), dosing and duration, and rationale for non‑formulary or non‑FDA use.
- Document how requested quantity relates to QL and why greater quantity is needed.
- Provide patient age when an AL applies.
- Supply clinical notes showing prior trials and failures when step therapy (ST) is required.
- For specialty products, include site of care, administration plan, and prior authorization forms as applicable.
Prior Authorization Submission and Response Times; Denial Notice
Submission and response times: urgent PA 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 a state law requires a faster response. If a request is denied or incomplete, the notice will explain the specific reasons for denial or identify missing information required to complete the request.
- If disapproved, notice of disapproval will state specific reasons and any missing material information.
- Follow the payer’s PA form and fax/phone submission instructions to avoid processing delays.
PA, Quantity Limits, and Specialty Pharmacy Denial Risk
PA and QL enforcement is active across the formulary; exceeding quantity limits or failing to obtain PA for PA‑required agents risks claim denial. Specialty (SP) status frequently accompanies PA requirements for high‑cost therapies.
- Quantity limits may trigger denials if the submitted quantity exceeds the QL without supporting documentation.
- Specialty pharmacy products often require PA and may be limited to specific fill quantities or sites of care.
- Failure to obtain PA for PA/SP drugs may result in denial or non‑coverage.
Step Therapy Requirements and Flags
Step therapy (ST) requirements apply to select products and therapeutic classes. Where ST is indicated, prior trials of preferred agents must be documented before approving non‑preferred therapies.
- Some anticonvulsants, dermatologic topicals, and other classes include ST requirements.
- Provider must document trials and outcomes of required first‑line agents to satisfy ST.
- No single explicit step‑therapy algorithm is embedded in the formulary summary; review drug‑specific lines for ST notes.
Age, New‑Start, and Supply Limit Notes
Operational notes: some products are age‑limited (AL) or have new‑start supply limits (e.g., opioids new starts limited to 7 days). Ensure the PA request includes age, indication, and justification for requests outside these limits.
- New start opioid supplies may be limited (e.g., 7‑day supply) — document need for longer duration.
- Age limits apply to many dermatologic and pediatric agents — include patient age on all requests.
- When requesting quantities above QL or exceptions for AL, attach clinical rationale and prior course of therapy.
Key Terms and Formulary Tiering
Initial Prescribing Limits and New-Start Controls
Initial therapy limits
Initial therapy is covered subject to the following initial‑use restrictions:
See butalbital entries
Initial therapy limits (prescribing restrictions)
Initial prescribing for opioid and certain analgesic products is covered when ALL conditions below are met:
See opioid product lines showing 'New starts limited to 7 day supply'
Initial topical acne therapy controls
Initial coverage for topical acne agents requires ALL of the following:
See topical acne entries for AL/QL/PA specifics
Initial therapy requirements (high level)
At initiation, coverage may require any of the following utilization steps:
See specific topical entries for ST/PA flags
Continuation / Ongoing Therapy
Continuation therapy
Continuation (ongoing) therapy is covered when ANY of the following apply:
Continuation implications drawn from QL/PA differences in product lines
Step Therapy Notes and Affected Products
| Policy point | Detail |
|---|---|
| Step Therapy (ST) | May require trying a specified preferred drug first before Ambetter covers an alternative; ST is defined in the formulary abbreviations and applied where 'ST' appears next to product entries. |
| Product / class | ST annotation / note |
|---|---|
| Fenoprofen calcium tablets | ILimits = QL(4 EA daily); ST — step therapy flag shown on product line. |
| Product / class | Utilization controls noted |
|---|---|
| Buprenorphine/naloxone (films, sublingual) | Multiple formulations include quantity limits (e.g., QL(2 EA daily), QL values shown) and some lines include PA — indicating utilization controls for opioid partial agonists. |
| Product / class | ST annotation / additional controls |
|---|---|
| Eslicarbazepine acetate; Lacosamide (APTIOM) entries | Entries include ST (step therapy) flags (e.g., APTIOM ILimits = QL(2 EA daily); ST; eslicarbazepine acetate ILimits = QL(2 EA daily); ST). |
| Observation | Implication |
|---|---|
| No explicit multi-step algorithm provided | Formulary shows ST flags on product lines but does not include an explicit stepwise algorithm in this excerpt; apply ST where 'ST' is annotated on specific entries. |
| Combination product | ST annotation |
|---|---|
| Amlodipine besylate - olmesartan medoxomil (combination) | ILimits = ST — combination products may be subject to step therapy as indicated on the product line. |
| Drug group / examples | SP / PA / ST notes |
|---|---|
| Antineoplastic / specialty agents (multiple entries) | Many entries are annotated SP and/or PA (e.g., methotrexate sodium SOLR ILimits = SP; PA); explicit multi-step ST sequences are not provided in this excerpt — specialty/PA requirements control access. |
| Annotation | Meaning / example |
|---|---|
| SP; PA | Indicates specialty pharmacy or site prior authorization plus prior authorization may be required; some entries list 'SP; PA' suggesting step/ specialty process prior to coverage. |
| Product | Utilization control / ST context |
|---|---|
| UPTRAVI titration pack | ILimits = max fill(s_perl 180 dayls) on titration pack (utilization control); UPTRAVI tablets (200 mcg) ILimits = PA — utilization controls applied; explicit ST sequence not shown. |
| Topical | ST / ILimits example |
|---|---|
| Sulfacetamide sodium with sulfur liquid; Tretinoin; Clobetasol propionate (topicals) | Several topical products include ST annotations (e.g., sulfacetamide sodium wl sulfur ILimits = AL(At least 12 yrs old); ST; clobetasol propionate FOAM ILimits = QL(3 GM daily); ST). |
| Context | Usage of ST annotation on product entries |
|---|---|
| ST on product entries | Products such as clobetasol propionate FOAM and GEL show 'ST' alongside QL and PA in some formulations; the ST annotation on a product line indicates a step edit exists and requires trial of preferred alternatives as documented. |
| Annotation | Interpretation / example |
|---|---|
| SP; PA on formulary rows | Some products are listed as 'SP; PA' which indicates a step or specialty requirement prior to prior authorization — i.e., step edits or specialty-channel requirements may be enforced before PA is granted. |
Quantity Limits by Product (Selected Examples)
Specialty Pharmacy and Site Restrictions
Arrange specialty pharmacy fulfillment for Tier‑4/specialty drugs
Specialty tier drugs may require fulfillment at participating specialty or hemophilia network pharmacies; providers should arrange dispensing through an in‑network specialty pharmacy when SP is indicated.
- If a product is on the specialty tier (Tier 4) and notes specialty fulfillment, confirm an in‑network specialty or hemophilia pharmacy will dispense.
- Contact the payer or check the Ambetter website pharmacy information for participating specialty pharmacies.
No explicit site‑of‑care restrictions present in extract
The extract contains no explicit site‑of‑care restrictions; when no site restriction is listed, usual dispensing or administration settings apply unless otherwise noted on the product row.
- If no site‑of‑care limitation appears on the formulary row, follow standard site‑of‑care practices unless payer guidance indicates otherwise.
- Confirm site‑of‑care requirements for specific agents if clinical circumstances suggest specialty administration is needed.
Coordinate specialty pharmacy or infusion‑center requirements for SP‑flagged agents
Some agents are designated 'SP' or 'Site Prior Authorization' indicating specialty pharmacy or infusion/infusion‑center site‑of‑care restrictions; providers must arrange dispensing/administration per those annotations.
- SP or 'Site Prior Authorization' flags may require infusion center administration or specialty pharmacy dispensing—confirm and coordinate prior to scheduling treatment.
- Obtain any site prior authorization if required for infusion or clinic administration of the listed agent.
Use specialty pharmacy dispensing for agents with 'SP' designation
An 'SP' designation on a formulary row indicates specialty pharmacy dispensing is required for that agent; providers should route prescriptions to an in‑network specialty pharmacy when SP is shown.
- Examples: multiple antineoplastic and specialty agents show SP—confirm specialty dispensing channel and PA prior to prescribing.
- Failure to dispense via the required specialty pharmacy may result in non‑coverage.
Formulary Purpose and Scope
The formulary lists FDA‑approved brand and generic drugs covered under the prescription benefit and explicitly states that generic drugs are considered first-line treatment when available. The list is periodically reviewed and may omit certain dosage forms or strengths; providers should confirm plan benefit limits and any per‑product utilization controls (for example, QL, PA, AL, ST) before prescribing or dispensing.
Biosimilar / Brand Mappings
Follow listed brand/biosimilar mapping (e.g., fludarabine SOLN → MVASI)
Formulary rows may show a brand/prug Name mapping (example: fludarabine phosphate SOLN listed with prug Name MVASI); use the listed mapping when confirming biosimilar/brand relationships for billing or PA.
- Fludarabine phosphate SOLN lists prug Name = MVASI and ZIRABEV—note these mappings when preparing PA or specialty pharmacy requests.
- Reference the formulary's prug Name entries to ensure correct product identification on claims and PA forms.
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