Centene Ambetter Formulary Coverage & Prior Auth

Coverage summary

This is a partial extract of the Ambetter Prescription Drug List (Formulary) titled Ambetter Prescription Drug List, effective 2026-01-01. The document presents a mixed coverage stance: many drugs and formulations are listed with tier assignments, utilization-management flags and limits (quantity limits, age limits), and some high-cost or specialty products require specialty handling. This extract focuses on formulary tiering, utilization-management flags and thresholds and specialty handling (partial list of entries and examples).

Key thresholds & policy info

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

Example QL — AdalimumabQL: 0.143 EA daily; many presentations also limited to 1 max fill per 180 days and PA

Example QL — ActemraQL: 3.6 mL per 28 days (retail); 4 mL per 28 days (mail); SP and PA noted

Effective dateEffective January 1, 2026

Policy numberAMB25-AHS-C-00023-OK

Scope summaryAmbetter prescription drug formulary listing covered drugs, tiering, QL/AL flags, prior authorization and specialty handling (partial extract)

Prior authorization & initial coverage criteria

Prior Authorization for Non-Formulary Drugs

Prior authorization required for non-formulary drugs; timeframes and notice requirements:

Provider action: Provider must complete the Prior Authorization form to request coverage of a non-formulary drug
Urgent request response: Urgent requests: services will respond via fax or phone within 24 hours of receipt of all necessary information24 hours
Response time measured from receipt of all necessary information
Non-urgent request response: Non-urgent requests: services will respond via fax or phone within 72 hours of receipt of all necessary information unless state law requires a faster response

Continuation and utilization flags

Utilization Management Flags (per drug entry)

Each drug entry includes one or more of the following utilization management flags:

Dispensing restrictions example: Some products have maximum fills over specified timeframes (e.g., naloxone retail OTC: 2 max fills per 30 days retail; naltrexone: 3 max fills per 365 days retail/mail); other products show 'Limit 1 fill every 90 days' for select groupsexamples per product row

Enforced per product and indicated on row

Formulary coverage entries

Each drug/class row indicates Tier and any restrictions (quantity limits, PA, SP, fill frequency). Example extracted entries (any of these may appear on a formulary row):

Example entries (partial)

Emtricitabine-tenofovir 100 MG-150 MG:

Non-formulary, non-covered and exception process

Non-formulary (NF) products are not covered unless you or your provider request an exception; providers must complete the Prior Authorization form to request coverage of a non-formulary drug. For non-formulary exception requests the plan will respond to urgent requests within 24 hours and non-urgent requests within 72 hours of receipt of all necessary information; denials will include specific reasons or identification of missing information. Some entries in the formulary are annotated as covered only for specific indications (for example, products marked “Covered for malaria treatment only”) and other products or non‑FDA uses may require prior authorization per the formulary notes.

Formulary codes and example drug entries

Formulary tiering (illustrative entries present in part)mixed

Tier 0	No copayment; preventive and mandated products per ACA
Tier 1A	Lowest copayment; select high-value drugs and some OTC
Tier 1B	Low copayment; value drugs compared to alternatives
Tier 2	Medium copayment; preferred brand drugs
Tier 3	High copayment; higher-cost brand and non-preferred generics
Tier 4	Specialty tier; specialty/hemophilia network requirements

Examples of drugs with tier/limits/PANDCCovered

ENBREL SOSY 25 MG/0.SML	Enbrel subcutaneous (specified strength)
ANDRODERM PT24 2 MG/24HR	Testosterone transdermal patch 2 mg/24 hr
ANDRODERM PT24 4 MG/24HR	Testosterone transdermal patch 4 mg/24 hr
danazol CAPS	Danazol capsules (androgenic agent)
methyltestosterone TABS	Methyltestosterone tablets
TESTOSTERONE MG/ML	Testosterone injection (mg/mL formulations)
ALPRAZOLAM TABS 0.25/0.5/1/2 MG	Alprazolam tablets, multiple strengths
diazepam (various)	Diazepam formulations and strengths
lorazepam (various)	Lorazepam formulations and strengths
ARNUITY ELLIPTA / fluticasone furoate	Inhaled corticosteroid product

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Opioid-related examplesNDCCovered

hydromorphone hcl SOLN IJ 10 MG/ML	Hydromorphone injection 10 mg/mL
hydromorphone hcl SOLN IJ 50 MG/ML	Hydromorphone injection 50 mg/mL
hydromorphone hcl SOLN IJ 500 MG/50ML	Hydromorphone injection 500 mg/50 mL
meperidine hcl SOLN IJ 25 MG/ML	Meperidine injection 25 mg/mL
meperidine hcl SOLN IJ 50 MG/ML	Meperidine injection 50 mg/mL
meperidine hcl SOLN IJ 100 MG/ML	Meperidine injection 100 mg/mL
meperidine hcl SOLN PO 50 MG/5ML	Meperidine oral solution 50 mg/5 mL
methadone hcl CONC	Methadone concentrated formulation
methadone hcl SOLN PO	Methadone oral solution
methadone hcl SOLN IJ 10 MG/ML	Methadone injection 10 mg/mL

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1/3

Anticoagulants and injectablesNDCCovered

fondaparinux sodium 10 MG/0.8ML	Fondaparinux prefilled syringe 10 mg/0.8 mL
ELIQUIS (apixaban)	Apixaban oral anticoagulant (multiple entries)
rivaroxaban (XARELTO)	Rivaroxaban oral anticoagulant (multiple entries)
enoxaparin sodium SOSY 80 MG/0.8ML	Enoxaparin prefilled syringe 80 mg/0.8 mL
enoxaparin sodium SOSY 120 MG/0.8ML	Enoxaparin prefilled syringe 120 mg/0.8 mL
enoxaparin sodium SOSY 30 MG/0.3ML	Enoxaparin prefilled syringe 30 mg/0.3 mL
enoxaparin sodium SOSY 60 MG/0.6ML	Enoxaparin prefilled syringe 60 mg/0.6 mL
enoxaparin sodium SOSY 100 MG/ML	Enoxaparin 100 mg/mL formulation
enoxaparin sodium SOSY 150 MG/ML	Enoxaparin 150 mg/mL formulation

Seizure and neurology agentsNDCCovered

VALTOCO 20 MG DOSE / LQPK 10 MG/O.1ML	Valtoco nasal spray 20 mg and 10 mg per 0.1 mL dose forms
VALTOCO 5 MG DOSE	Valtoco 5 mg dose nasal spray
BANZEL TABS 200 MG	Rufinamide tablets 200 mg
BANZEL TABS 400 MG	Rufinamide tablets 400 mg
carbamazepine CHEW/CP12/TABS/SUSP/TB12	Carbamazepine multiple formulations including chewable and suspension
DIACOMIT CAPS 250 MG	Stiripentol (Diacomit) 250 mg capsules
DIACOMIT CAPS 500 MG	Stiripentol 500 mg capsules
rufinamide SUSP	Rufinamide suspension
rufinamide TABS 200 MG	Rufinamide tablets 200 mg
rufinamide TABS 400 MG	Rufinamide tablets 400 mg

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Psychiatric and CNS agentsNDCCovered

SSRIs: citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline	Selective serotonin reuptake inhibitors (multiple formulations and strengths)
SNRIs and desvenlafaxine/duloxetine	Serotonin-norepinephrine reuptake inhibitors and related agents
POMALYST	Pomalidomide (antineoplastic immunomodulator) - specialty handling
FANAPT TITRATION PACK A	Iloperidone titration pack
risperidone (microspheres/SOLN/TABS/TBDP)	Risperidone multiple formulations including long-acting injection

Antiemetics and supportive careNDCCovered

ANZEMET	Dolasetron (5-HT3 antagonist)
granisetron	Granisetron (5-HT3 antagonist)
ondansetron	Ondansetron (5-HT3 antagonist)
LIQD naloxone	Naloxone liquid formulations
SOLN 0.4 MG/ML naloxone	Naloxone 0.4 mg/mL solution
4 MG/10ML naloxone	Naloxone 4 mg per 10 mL formulation

Oncology agents and categories (selected entries)NDCCovered

GLEOSTINE 100 MG	Lomustine 100 mg capsules
ifosfamide SOLN 1 GM/20ML	Ifosfamide solution 1 g/20 mL
oxaliplatin SOLN 100 MG/20ML	Oxaliplatin solution 100 mg/20 mL
clofarabine	Clofarabine formulations
decitabine	Decitabine formulations
floxuridine	Floxuridine formulations
fludarabine phosphate SOLN	Fludarabine phosphate solution
fluorouracil 500 MG/10ML	5-FU 500 mg/10 mL vial
VECTIBIX 100 MG/5ML	Panitumumab 100 mg/5 mL
VIZIMPRO	Dacomitinib

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Antiparkinson, movement disorder, and akinetic agentsNDCCovered

benztropine mesylate	Benztropine formulations
selegiline hcl CAPS	Selegiline capsules
trihexyphenidyl hcl SOLN/TABS	Trihexyphenidyl solution and tablets
amantadine hcl CAPS/SOLN/TABS	Amantadine across formulations
bromocriptine mesylate CAPS/TABS	Bromocriptine formulations
carbidopa-levodopa TABS/TBCR/TBDP	Carbidopa-levodopa multiple formulations

HIV and antiviral agents (selected combos)NDCCovered

COMPLERA	Emtricitabine-rilpivirine-tenofovir DF combination
emtricitabine-rilpivirine-tenofovir disoproxil fumarate	Combination product entries
efavirenz	Efavirenz formulations and doses
etravirine 100/200 MG	Etravirine tablet strengths

Diabetes and combination therapiesNDCCovered

GLYXAMBI	Empagliflozin/linagliptin
JANUMET XR/TABS	Sitagliptin/metformin extended release
pioglitazone combos	Pioglitazone combination products
saxagliptin-metformin	Saxagliptin/metformin combination
SOLIQUA	Insulin glargine/lixisenatide combination
SYNJARDY XR/TABS	Empagliflozin/metformin XR
TRIJARDY XR	Metformin/empagliflozin/linagliptin triple combo

Insulins and concentrated insulinsNDCCovered

HUMULIN R U-500 CONCENTRATED SOLN SC / KWIKPEN	Human insulin U-500 concentrated formulations
INSULIN ASPART	Insulin aspart products
INSULIN GLARGINE	Insulin glargine products
INSULIN LISPRO	Insulin lispro products
NOVOLIN	Novolin insulin products
NOVOLOG	Novolog insulin products

Antibiotics, antiretrovirals, and broad alphabetical entriesmixed

abacavir sulfate SOLN/TABS	Abacavir formulations
abiraterone acetate 250 MG	Abiraterone 250 mg
abiraterone acetate 500 MG	Abiraterone 500 mg
many alphabetical entries (acamprosate, acarbose, acebutolol, etc.)	Comprehensive alphabetical listing included in full formulary

Remaining specialty and therapeutic classes (groups)mixed

Antineoplastic Hormonal and Related Agents	Group listing - see formulary for specifics
Antineoplastic Immunomodulators	Group listing - see formulary for specifics
Antineoplastic Antibiotics	Group listing - see formulary for specifics
Antineoplastic Enzyme Inhibitors	Group listing - see formulary for specifics
Antineoplastic Combinations	Group listing - see formulary for specifics
Topoisomerase Inhibitors	Group listing - see formulary for specifics

What providers must do

Prior Authorization

Prior authorization for non-formulary drugs

Prior authorization is required for non-formulary drugs. Providers must submit a completed Prior Authorization form. Urgent requests will be responded to within 24 hours of receipt of all necessary information; non-urgent requests within 72 hours, unless state law requires a faster response. If a request is disapproved, the notice of disapproval will include a clear explanation of the specific reasons or, if incomplete, identify the missing material information needed to complete the request.

Provider must complete and submit the PA form for NF drugs.
Response timelines: 24 hours for urgent requests; 72 hours for non-urgent requests (state law may require faster).
Disapproval notices must state specific reasons or missing information.

Prior Authorization

Prior authorization for certain formulary products

Prior authorization is required for certain formulary specialty and higher-cost products. Providers should check formulary flags (PA) for listed agents and submit PA when indicated.

Examples of products commonly requiring PA or special handling: adalimumab products (multiple entries), ARIKAYCE, ACTEMRA, ENBREL, OTEZLA.

Clinical evidence & definitions

Definitions and abbreviations used in the formulary extract (as presented in the document): AL = Age Limit (some drugs only covered for certain ages); QL = Quantity Limit (limits on amount dispensed per day, per fill, or per period); PA = Prior Authorization (pre-approval required before coverage); ST = Step Therapy (required prior trials before coverage); SP = Specialty Drug (may require specialty pharmacy fulfillment); SF = Split Fill (initial 15-day increments until stabilized); NF = Non‑formulary (not covered unless exception requested); RX/oTC = prescription and over‑the‑counter forms. No clinical trials or evidence summaries are included in this part of the extract.

Background and scope

Background: The Ambetter Formulary guides covered brand and generic drugs under the prescription drug benefit. Generic drugs are preferred first-line when available; preferred brand drugs are identified on lower tiers when clinically appropriate. The Formulary is periodically reviewed and may change; not all strengths or dosage forms may be covered. Plan-specific benefit designs may impose additional coverage limits or different cost sharing. This output is a partial extract of the Ambetter Formulary (January 2026).

Known data quality issues in this extract: entries are fragmented in places, tier mappings and flag placements may be inconsistent across lines, and there are formatting artifacts (e.g., corrupted fields and 'prug Name' mapping artifacts). Consult the full Ambetter formulary or the payer for authoritative coding, exact benefit coverage, and limits before making coverage or billing decisions.

Revision history

2026-01-01partial_extractLatest

Partial extract (part 3 of 15) from Ambetter Formulary Updated January 2026 — this segment lists tiers, quantity limits (QL), age limits (AL), prior authorization (PA), specialty (SP) flags and fill-frequency constraints for numerous products; no explicit revision history present in this segment.

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Ambetter Formulary (Prescription Drug List) - January 2026