Centene Ambetter Drug Formulary Coverage Update

Formulary Coverage Criteria

Formulary coverage criteria

Formulary coverage and restrictions are defined by tiers and per-product limits/requirements

Formulary coverage basics: Drugs listed on the formulary are covered under the prescription drug benefit subject to tier placement; generics are preferred when available; tiers (Tier 0, 1A, 1B, 2, 3, 4) determine copayment and handling

See Drug List Key for tier definitions

Utilization management types: Coverage of individual products may be restricted by one or more of: Prior Authorization (PA), Step Therapy (ST), Quantity Limits (QL), Age Limits (AL), Specialty Pharmacy routing (SP), or max-fill/package intervals as shown on product rows

Flags (PA/ST/QL/AL/SP) appear inline on formulary rows

Opioid new-start restriction: New opioid starts are limited to a 7‑day supply; allowance up to two 7‑day fills during any 28‑day period and up to 28 non‑consecutive days in any 90‑day period; claims exceeding these limits require prior authorization7 day initial supply; up to two 7‑day fills per 28 days; up to 28 days per 90 days

Applies across opioid product entries

Coverage conditions for adalimumab products (formulary entries)

Formulary listing shows coverage with quantity limits and prior authorization for multiple adalimumab biosimilars and starter kits when conditions below are met:

Adalimumab product coverage: Requested adalimumab product is listed on the formulary and within the applicable tier; product-level quantity limits apply (common daily-equivalent QL(0.143 EA daily)) and many presentations require prior authorization (PA)QL(0.143 EA daily) and package limits such as 1 max fill per 180 days for starter kits

Starter kits and certain package presentations limited to 1 fill per 180 days; PA required as indicated on line items

Coverage conditions for specialty injectables

Specialty injectables (e.g., ARIKAYCE, ACTEMRA) are listed with PA and QL restrictions.

Specialty injectable coverage: Coverage for listed specialty injectable products requires prior authorization when indicated and fulfillment may be routed via specialty pharmacy (SP); product entries include specific quantity limits (e.g., ACTEMRA ACTPEN QL(3.6 mL per 28 days retail; 4 mL per 28 days mail))various QL per 28‑ or 180‑day intervals as shown per product

Site-of-care/SP handling may be required for some antineoplastics and specialty biologics

Coverage for PDE4 inhibitor (OTEZLA)

OTEZLA entries include age limits, quantity limits, and PA.

OTEZLA coverage: Coverage of OTEZLA (apremilast) requires prior authorization; certain presentations include an age limit (AL) and quantity limits (QL) — example: AL(At least 45 yrs old Up to 79 yrs old) and QL(2 EA daily)Age >=45 and <=79 for specified entries; QL(2 EA daily)

Starter/package presentations may also have max‑fill per 180 days and PA flags

Step therapy/first-line requirement for certain ACTEMRA entries

Some ACTEMRA formulations note a drug trial requirement.

NSAID trial prior to coverage: Coverage of a specified ACTEMRA presentation requires documentation of a prior trial of ibuprofen ('Must try ibuprofen') before coverage is approvedTrial of ibuprofen documented

The formulary line does not specify duration or failure criteria; document trial in PA request

Formulary coverage controls (partial)

Coverage and utilization controls observed in this segment (examples follow):

New start opioid supply restriction: For many opioid products listed, new starts are limited to a 7‑day supply7 day

Appears repeatedly across hydromorphone, meperidine, methadone, morphine, acetaminophen‑codeine, hydrocodone combinations

Quantity limits: Specific formulations have per‑day or per‑fill quantity limits (QL) such as QL(6 EA daily), QL(1 EA daily), QL(0.146 mL), QL(100 mL daily), QL(3.2 GM)see product lines

Limits vary by product and strength and are shown on each formulary row

Prior authorization requirement: Certain formulations require prior authorization (PA) as noted in‑line (examples include ENBREL entries and select opioid or specialty formulations)

Formulary coverage summary (excerpt)

Coverage and utilization management rules in this excerpt are conveyed by tier assignment, quantity limits, and PA indicators.

Tiering and utilization controls: Drugs are assigned tiers (Tier 0–4) that determine formulary preference and member cost share; many entries include quantity limits (QL) and some include prior authorization (PA) or specialty (SP) indicators which must be satisfied for coverageObserve QL/AL/PA values on each product line

Formulary is not exhaustive; consult full plan documents for benefit‑specific rules

Formulary product lines (cardiovascular combinations)

Coverage statements as formulary entries (tier, ILimits, PA noted where present).

ACE inhibitor/hydrochlorothiazide combinations: Multiple ACE inhibitor + hydrochlorothiazide combination products are listed with tier assignments and product‑specific quantity limits (e.g., QL(1–4 EA daily) depending on product) and PA flags where shownsee per‑product QL values

Tier placement may vary (1A/1B/3) across formulations

Anti-infectives

Anti-infective and antiprotozoal agents with tiers and limits.

Anti‑infective coverage: Anti‑infective class entries include tier assignments and quantity limits (e.g., Anti‑infective Agents Misc. QL(4 EA daily; 40 EA per fill retail)); select products (XIFAXAN) include age limits and PA flagssee product rows (e.g., XIFAXAN 200 MG: 9 EA per 3 days; AL(>=12 yrs); PA)

Some formulations require PA or have per‑course QLs

Antimalarials - restricted use

Antimalarial agents are flagged as 'Covered for malaria treatment only' with fill-frequency and quantity limits for several products.

Antimalarial restricted coverage: Atovaquone‑proguanil and other antimalarials are covered only for malaria treatment and are subject to fill frequency and quantity restrictions (example: Limit 1 fill every 180 days; QL(12 EA per fill); 1 max fill per 180 days)1 max fill per 180 days; QL(12 EA per fill)

PA may be required for some antimalarial combinations

Chemotherapy agents (PA/SP controls)

Antineoplastic agents and supportive oncology drugs with tiers, QL, SP and PA controls.

Antineoplastic access controls: Coverage for chemotherapy and adjunctive oncology agents is subject to specialty handling (SP) and prior authorization (PA) where indicated; some agents have per‑day or per‑fill quantity limits (QL) documentedsee per‑drug QL/SP/PA entries (e.g., oxaliplatin QL(3 EA daily); many agents flagged SP; PA)

Site-of-care and specialty routing may apply for multiple antineoplastic agents

Covered with utilization controls

Coverage for listed drugs is subject to utilization controls

Standard utilization requirements: Drug coverage requires adherence to the formulary row indicators: follow the listed tier, obtain prior authorization when 'PA' is shown, route via specialty pharmacy when 'SP' is shown, observe step therapy flags (ST), and do not exceed quantity limits (QL)see per‑product ILimits

Medical necessity and full clinical criteria (if any) are maintained in separate authorization policies

Formulary product coverage (partial)

Formulary coverage entries and utilization rules (partial list) — each product entry includes tier, limits, and utilization management indicators.

Topical/dermatologic controls (sample): Topical dermatologic products commonly include age limits (e.g., AL(At least 12 yrs old)), per‑day or per‑fill quantity limits (QL values such as 3 GM daily, 15 GM per 30 days), and may require PA or ST as indicatedAL(>=12 yrs) and product‑specific QL values

Examples include clindamycin phosphate combinations, tretinoin, calcipotriene‑betamethasone lines

General PA requirement for non‑FDA uses

Coverage and authorization notes present in excerpt

PA for non‑FDA uses: Non‑FDA approved uses of listed products require prior authorization as noted; coverage for off‑label uses is contingent on PA and supporting documentationPA required for non‑FDA uses

Appears for multiple topical, diagnostic and other product groups

The Formulary lists FDA‑approved brand and generic medications covered under the prescription drug benefit and indicates that generics are preferred when available. It is intended as a coverage guide; generics should be considered first‑line where available, and preferred brand drugs are identified for situations where a generic is not suitable.

The extract reviewed does not include any explicit clinical exclusion or ineligibility conditions (e.g., specific diagnoses or patient populations that are categorically excluded) within the cited formulary lines. Coverage statements in this segment focus on tiering, quantity limits (QL), age limits (AL), and prior authorization (PA) flags rather than listing clinical exclusions.

Non‑FDA‑approved uses of several topical and diagnostic products require prior authorization. When an item is noted as requiring PA for non‑FDA uses, providers must submit supporting documentation of medical necessity per the payer's prior authorization process before those uses will be considered for coverage.

The reviewed segments do not contain explicit statements labeling any product or formulation as 'Not Medically Necessary.' Formulary lines in these chunks instead record coverage attributes such as tier assignment, QL/AL values, and PA or ST flags; absence of an explicit NMN designation in these extracts does not imply NMN language is not present elsewhere in the full policy.

Within the examined extract there are no explicit 'not medically necessary' determinations applied to specific products. Coverage information is conveyed through utilization controls (e.g., PA, QL, AL, ST) rather than explicit NMN statements in these chunks.

This segment does not include explicit 'Not Medically Necessary' (NMN) language for the products shown. Formulary entries here emphasize quantity limits and tier placement without introducing NMN findings in the cited lines.

Formulary Coding, Flags and Limits

Formulary drug row annotations (QL, AL, PA, ST, SP)mixed

QL(2 EA daily)	Quantity limit examples as shown in drug rows
AL(At least 6 yrs old)	Age limit examples as shown in drug rows
PA	Prior authorization required as listed in drug rows
ST	Step therapy indicator in drug rows
SP	Specialty tier indicator

No CPT/HCPCS/ICD/NDC codes presentmixed

No codes listed

Formulary drug entries and special-formulation codesmixed

OTEZLA TABS	Otezla tablets — ILimits QL(2 EA daily); PA; age limits noted
ENBREL SURECLICK	Enbrel SureClick — ILimits QL(.146 ML daily); PA
ENBREL SOSY 50 MG/ML	Enbrel 50 mg/mL syringe — ILimits QL(0.286 ML daily); SP; PA
butalbital-acetaminophen-caffeine CAPS 40 MG-50 MG-325 MG	Butalbital-containing combination capsules — tiers and QL vary; some require PA
hydromorphone hcl SOLN IJ 10 MG/ML	Hydromorphone solution — New starts limited to 7 day supply; QL(100 ML daily)
hydromorphone hcl TABS	Hydromorphone tablets — New starts limited to 7 day supply; QL noted
meperidine hcl SOLN IJ 100 MG/ML	Meperidine solution — PA; New starts limited to 7 day
methadone hcl SOLN PO 5 MG/ML	Methadone oral solution — QL(100 ML daily) or other daily QL; PA noted
morphine sulfate CP24	Morphine sulfate controlled-release — New starts limited to 7 day supply; QL limits
acetaminophen w/ codeine TABS 15 MG-300 MG	Acetaminophen/codeine tablets — New starts limited to 7 day supply; QL values vary

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Formulary entries (no procedure codes)mixed

no CPT/HCPCS present

This extract contains drug names, tiers and limits but no procedure or billing codes were listed in these chunks.

Formulary product entries (partial)NDC|drug_name_mapped

XARELTO TABS 15 MG	rivaroxaban — Tier and QL entries present
enoxaparin sodium 300 MG/3ML	enoxaparin formulations with QL and PA flags
fondaparinux sodium 2.5 MG/0.5ML	fondaparinux with QL and tier entries
NAYZILAM	nasal midazolam — listed with QL and PA
VALTOCO 15 MG/DOSE	diazepam/lorazepam analogs listed with QL
DIACOMIT PACK 250 MG / 500 MG	stiripentol products listed with QL
BRIVIACT SOLN PO 10 MG/ML	brivaracetam solution with QL; PA
BANZEL TABS 200 MG / 400 MG	rufinamide with QL; PA
vigabatrin PACK / TABS	vigabatrin with QL; SP; PA
SPRAVATO (56 MG/84 MG DOSE)	esketamine nasal — listed with PA and tier info

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Formulary product referencesNDC|brand

XIFAXAN 200 MG	rifaximin 200 mg (product line referenced with AL and PA constraints)
XIFAXAN 550 MG	rifaximin 550 mg (product line referenced with QL and PA)

Antineoplastic agentsbrand|generic

cisplatin SOLN 100	cisplatin solution 100 (tier 4; ILimits = SP; PA)
busulfan SOLN	busulfan solution (ILimits = SP; PA)
melphalan hcl IV	melphalan hcl IV (tier 1B; listed)

Utilization control codes and indicatorsmixed

QL(1 EA daily)	Quantity limit example shown for several agents
QL(2 EA daily)	Quantity limit example shown for several agents
QL(0.143 EA daily)	Quantity limit example shown for agents such as TRAZIMERA and GILOTRIF
SP	Specialty Pharmacy indicator
PA	Prior Authorization indicator

Formulary utilization codes (QL, AL, PA)mixed

QL(8 EA daily)	quantity limit example for entacapone
QL(2 EA daily)	quantity limit example for carbidopa-levodopa TABS
QL(0.072 EA dailylPA	quantity limit shown for PERSERIS PRSY (format from doc)
AL(At least 18 yrs old)	age limit example
PA	prior authorization flag

Formulary flags and quantity limitsmixed

QL(1.67 GM daily)	quantity limit example for betamethasone valerate FOAM
QL(8 ML daily)	quantity limit example for betamethasone valerate OINT
QL(4 GM daily)	quantity limit example for calcipotriene-betamethasone dipropionate
PA	prior authorization flag (appears for multiple entries)
ST	step therapy flag (appears for multiple entries)
QL(3 GM daily)	quantity limit example for hydrocortisone butyrate OINT
QL(15.15 GM daily)	quantity limit example for hydrocortisone topical CREA/SOLN entries
QL(2 GM daily)	quantity limit example for clobetasol propionate GEL/CREA
QL(3.5 GM daily)	quantity limit example for halobetasol propionate
QL(0.082 ML daily)	small-volume QL noted for some DUPIXENT-mapped entries

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inv-35: Opioid new-start limits — new starts limited to 7-day supply with allowed fills in 28/90-day windows

New-start restrictionNew opioid starts limited to a 7-day supply; providers may submit PA for fills exceeding limits

28-day window allowanceAllow up to two 7-day fills during any 28-day period

90-day window allowanceAllow up to a total of 28 non-consecutive days supply in any 90-day period (applies cumulatively across opioids)

Denial riskFills exceeding the new-start allowance may be denied without prior authorization or justification

Prior Authorization, Step Therapy and Documentation

Prior Authorization

Prior Authorization Submission, Timing and Required Documentation

Prior Authorization (PA), Step Therapy (ST), Specialty (SP) flags and quantity/age/package limits are applied across the formulary. Providers must submit a completed Prior Authorization form and supporting documentation (clinical rationale, prior treatment history, age/weight information, and package/dispense justification) when PA is indicated. Urgent requests: response within 24 hours of receipt of all necessary information. Non‑urgent requests: response within 72 hours unless state law requires a faster response. Incomplete PA requests may be denied; a denial will explain missing information or clinical reasons.

Required information for PA: diagnosis, prior therapies tried (including step therapy attempts), member age/weight when relevant, requested dose/quantity and justification for package/starter kit limits, and NDC or product name as shown on formulary.

Prior Authorization

PA and Specialty Routing for Biologics, Injectables and Oncology Drugs

Many high-cost biologics, specialty injectables, oncology agents, and some antivirals require prior authorization and/or specialty routing. PA is required for most adalimumab products and starter kits (package and 180‑day max‑fill limits apply); submit documentation supporting package limits and clinical indication. Antineoplastic agents frequently require both PA and enrollment in a specialty/site program (SP) before coverage; failure to obtain PA/SP can result in claim denial.

Terms and Abbreviations

inv-129: Formulary tiers and brief meanings (Tier 0–4)

Tier definitions (summary)Tier 0–4: Tier 0 (no copay prevention drugs); Tier 1A/1B/1 (low copay); Tier 2 (medium copay preferred brands); Tier 3 (high copay/non-preferred); Tier 4 (specialty)

Specialty channelSpecialty-tier drugs may require fulfillment at participating specialty or hemophilia network pharmacies

Tier impacts cost/shareTier assignment indicates formulary preference and likely member cost share

inv-130: Formulary abbreviations (PA, ST, QL, NF, SP, SF)

Common abbreviationsPA = Prior Authorization; ST = Step Therapy; QL = Quantity Limit; NF = Non-formulary; SP = Specialty; SF = Split Fill

Usage contextAbbreviations are shown inline next to product entries to indicate utilization controls

Initial Therapy and Starter Fill Controls

Initial therapy controls

Initial fill and supply controls

Opioid new starts: New opioid prescriptions are limited to a 7‑day supply; up to two 7‑day fills allowed in any 28‑day period and up to 28 non‑consecutive days in any 90‑day period; fills beyond these limits require prior authorization7 day initial supply; up to two 7‑day fills per 28 days; up to 28 days per 90 days

Providers should include justification when requesting coverage beyond initial limits

Initial step requirement

Formulary notes a required trial for at least one product group.

Initial step requirement: Certain products require trial of a listed lower‑step agent before coverage (example: 'Must try ibuprofen' documented as required prior to coverage of a specified formulation)Documented trial of specified preferred agent

Step Therapy Rules and Affected Products

Example	Policy note
Lisdexamfetamine (capsules; chewable)	Listed with ST (step therapy) indicating a required trial of preferred stimulant agent(s) before coverage of lisdexamfetamine.

Example	Policy note
Specified ACTEMRA formulation entries	'Must try ibuprofen' is stated as a prerequisite trial prior to coverage for the listed formulation.

Example	Policy note
Butalbital-containing combination products (various capsules/tablet strengths)	Appear in multiple tiers; some presentations include PA and differing QL entries, indicating tier placement may affect PA/step application.

Example	Policy note
Tier assignments across product lines	Tier designations (Tier 1A/1B/2/3/4) indicate preferred ordering; explicit step durations or number of required failures are not specified in the excerpt.

Example	Policy note
NAYZILAM (nasal midazolam) listing	Formulary line shows QL and an 'ST' indicator on one entry, demonstrating presence of an ST flag on the product line.

Example	Policy note
Insulin sensitizing agents / higher-tier classes	Tiering combined with 'SP; PA' or similar flags implies required programmatic steps (e.g., specialty routing or prior authorization) before accessing higher-tier therapies.

Example	Policy note
Antihypertensive combination products (multiple combos listed)	Several combination antihypertensives are labeled 'ST' in the formulary, showing ST flags applied to combination products.

Example	Policy note
Antineoplastic class entries (cisplatin, busulfan, others)	Many antineoplastic entries include 'SP; PA' or 'PA' indicating controlled access pathways (specialty pharmacy/site-of-care and prior authorization) before coverage.

Example	Policy note
Apomorphine hydrochloride entry	Listed with QL and 'ST.' indicating a step therapy requirement for that agent/formulation.

Example	Policy note
Verapamil / pulmonary hypertension–related entries; treprostinil/digoxin lines	Entries show 'PA' or 'SP; PA' flags, demonstrating that step or specialty program enrollment and prior authorization are used for some cardiovascular/pulmonary hypertension agents.

Example	Policy note
Topical combination acne/dermatologic agents (e.g., calcipotriene‑betamethasone dipropionate; clindamycin–benzoyl peroxide)	Some topical combination products are flagged 'ST', indicating step therapy applies to topical combination agents shown in the formulary.

Example	Policy note
Topical formulations (clindamycin phosphate topical lines, tretinoin, adapalene, etc.)	Multiple topical entries include 'ST' in the ILimits or indicate age/QL constraints, showing topical formulations may be subject to step therapy requirements.

Example	Policy note
Clobetasol propionate foam and gel formulations	Clobetasol propionate FOAM and GEL lines include QL values and are annotated with 'ST', indicating step therapy flags on these topical corticosteroid formulations.

Example	Policy note
Higher-tier products and specialty/PA flagged agents	Tier assignments and PA/SP markers indicate preferred agents at lower tiers; higher-tier agents frequently require prior authorization or stepping through preferred alternatives before coverage is allowed.

Quantity and Age Limits by Product

Specialty Pharmacy, Infusion and Site-of-Care Notes

Note

Policy Background

The Formulary is a guide to FDA‑approved brand and generic medications covered under the prescription drug benefit; it is not a complete list. Not all dosage forms or strengths may be covered, and specific prescription benefit plan designs may exclude certain products or categories even if they appear in this document. Check the member's benefit plan for coverage limitations and member cost‑share.

OpenPayer

Ambetter Prescription Drug Formulary — Coverage Criteria