Ambetter Formulary (Prescription Drug List) - January 2026
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This document is the Ambetter prescription drug formulary (Prescription Drug List) effective January 1, 2026; it describes covered drugs, tiering, formulary keys/abbreviations, prior authorization process for non-formulary drugs, quantity/age/step-therapy limits and specialty/split-fill handling. Part 1 contains general formulary policies, drug list key definitions, opioid fill limits, and many sample drug entries with tiers and limits (partial list).
Document is part of Ambetter Formulary Updated January 2026; this part lists tiers, ILimits and PA flags for numerous products.
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).
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 response72 hours
State law may require faster response
- Disapproval notice content: If request is disapproved, notice will contain clear explanation of the specific reasons for disapproval or identification of missing material information if incomplete
Must state reasons or identify missing material information
From provider actions summary
Opioid new-start limits
Limits for opioids identified on the formulary as 'New starts limited to 7 day supply':
Opioid new-start enforcement
- New start supply limit: New starts limited to 7-day supply7 days
Applies to new opioid starts as identified on formulary
- 28-day period fills: Allow up to two 7-day fills during any 28-day period2 x 7-day fills per 28 days
Counts fills within any 28-day period
- 90-day period cumulative limit: Allow up to a total of 28 non-consecutive days supply in any 90-day period28 days per 90 days
Non-consecutive days count toward 28-day cap
- Cumulative across opioids: Limit applies cumulatively to all opioid medications filled
Applies across opioid products/classes
- Prior Authorization for exceptions: For fills exceeding these limits, provider may submit a Prior Authorization request
Exceptions processed via PA
From provider actions summary
Formulary Abbreviations and Operational Rules
Definitions and operational meaning for formulary abbreviations and operational notes:
Formulary codes - definitions
- AL (Age Limit): AL = Age Limit; some drugs covered only for certain agese.g., AL(At least N yrs old)
Examples: AL(At least 2 yrs old); AL(At least 12 yrs old)
- QL (Quantity Limit): QL = Quantity Limit; some drugs covered only for a certain amountformat QL(x EA daily) or QL(x ML daily) or per fill
Examples include per day, per fill retail/mail and per X days caps
- PA (Prior Authorization): PA = Prior Authorization; provider must obtain approval before coverage
Provider must submit PA when product flagged PA
- ST (Step Therapy): ST = Step Therapy; member must try specified drugs first before coverage of others
May require trial of preferred agents first
- NF (Non-Formulary): NF = Non-formulary; not covered unless exception requested
Exception via prior authorization
- RX/oTC = Prescription and OTC; drug may be available as prescription or over-the-counter
Plan may designate OTC vs Rx rules (e.g., naloxone)
- SP (Specialty): SP = Specialty Drug; may have special fill requirements and specialty pharmacy network fulfillment
Specialty-tier drugs may require specialty pharmacy
- SF (Split Fill): SF = Split Fill; initial fills may be 15-day increments until stabilized (restriction may lift after 90 days)15-day increments initially; restriction may lift after 90 days
Operational split-fill rule
- D/D+/c = indicates alternative copays for certain benefit designs; consult benefit documents
Not applicable for some plans; consult benefit documents
See formulary overview and Drug List Key
Continuation and utilization flags
Utilization Management Flags (per drug entry)
Each drug entry includes one or more of the following utilization management flags:
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: emtricitabine-tenofovir disoproxil fumarate 100 MG-150 MG — Tier 3; QL(1 EA daily)QL(1 EA daily)
Tier noted as 3 in one entry
- PIFELTRO (listed near emtricitabine-tenofovir entries) — Tier 3
Tier shown
- EMTRIVA SOLN — Tier 3; QL(24 ML daily) (also appears as Tier 1B elsewhere with QL(12 ML))QL(24 ML daily)
Conflicting tier lines shown in extract
- FUZEON SOLR — Tier 4; SP; PA
Special program and prior authorization flags present
- TRIUMEQ TABS — Tier 3; QL(1 EA daily); TRIUMEQ PD TBSO entry shows PAQL(1 EA daily)
Some related starter-pack PD entries show PA
- Hepatitis and CMV agents: CMV and Hepatitis agents often show fill-frequency caps (e.g., Limit 1 fill every 90 days; QL(10 EA per fill retail/mail); 1 max fill per 90 days) and may carry PA/SPe.g., 1 fill per 90 days
Group-level fill limits shown in extract
- Cardiovascular agents examples: Many cardiovascular agents show QL per day (e.g., QL(1 EA daily)) and may include D+ or PA flags; examples include verapamil lines and warfarin QL per 180 daysQL per day or per period
Tier and QL shown on rows
Entries are illustrative from the partial extract
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
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 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 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.
- Many specialty and injectable biologics have PA flags — verify per-drug requirements prior to dispensing.
Opioid new-start quantity enforcement
New-start opioid fills and ongoing opioid quantity are limited. Limits are enforced at point-of-sale; providers may request prior authorization for medically necessary exceptions. Requests for fills exceeding limits may be denied if not supported.
- New starts are limited to a 7-day supply.
- Allow up to two 7-day fills during any 28-day period (i.e., two short fills permitted in a 28-day window).
- Total allowed: up to a cumulative 28-day supply (non-consecutive) in any 90-day period across all opioid medications.
- For fills exceeding these limits, providers may submit a Prior Authorization request for exceptions.
- Exceeding the limits without an approved PA risks claim denial.
Specialty drug fulfillment
Certain products are designated Specialty (SP) and may require fulfillment via the plan's specialty or hemophilia network pharmacies. Specialty handling and SP designation may also trigger PA, limited distribution, or special clinical management requirements.
- Specialty drugs may require dispensing by a participating specialty network pharmacy.
- SP-designated agents frequently include oncology biologics, injectable biologics, and complex therapies.
- Example agents noted with SP considerations: oncology biologics, FUZEON, treprostinil.
- Providers should verify specialty pharmacy requirements and preferred vendors before prescribing/dispensing.
Quantity limits enforcement
Quantity limits are enforced per-day, per-fill, or per-specified-interval and will be applied at point-of-sale. Excess quantities may be denied or require prior authorization; providers should document medical necessity when requesting exceptions.
- Quantity limit formats include per-day caps, per-fill maximums, and interval-based totals (e.g., 28-day, 90-day windows).
- Examples of enforced limits: warfarin, enoxaparin, and naloxone have specified QLs or limits noted on the formulary.
- OTC vs Rx distinction: naloxone coverage and limits may vary by OTC vs prescription presentation — verify formulary entry before dispensing.
- Exceeding documented QLs at point-of-sale may be denied or require PA and supporting documentation.
- Providers must follow formulary tier and QL rules and submit PA with documentation when seeking coverage beyond limits.
Step therapy applies
Step therapy (ST) requirements apply to selected products. When ST is in effect, members must try designated preferred alternatives (steps) before higher-tier or non-preferred products will be covered. Providers may request an exception or submit documentation showing why step requirements should be waived.
- Step therapy applies to certain products and will map to preferred alternative agents as specified on the formulary.
- When an ST flag is present, coverage for the requested drug may require prior trial and failure of the preferred agent(s).
- Providers should reference product-level ST mappings on the formulary and document prior therapy or medical rationale when requesting PA or exceptions.
Age and indication documentation
Age limits and indication documentation are required for some drugs. Providers must document patient age and clinical indication to support coverage when AL or indication-based restrictions are present.
- Age limits (AL) apply to select products — coverage may be restricted to specified age ranges.
- Examples: some topical antifungals (e.g., miconazole) and certain estradiol vaginal products have age-related notes or indication limits.
- Providers must document age and clinical indication in the PA or claims record to support coverage and avoid denials.
Non‑FDA uses require documentation / PA
Non‑FDA (off‑label) uses frequently require documentation and may require prior authorization. Provide clinical rationale, supporting literature, and pertinent patient history when seeking coverage for non‑FDA indications.
- Non‑FDA uses require documentation and often a PA.
- Examples include pancreatic enzyme replacements such as CREON and ZENPEP when used for indications not explicitly FDA‑labeled.
- Clinical notes, diagnoses, and prior therapy history should accompany PA requests for off‑label uses.
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
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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