CurrentCentenePolicy N/A

Formulary drug coverage and alternatives (Coverage Criteria)

Lists drugs not covered by the plan and formulary alternatives, formulary restrictions (PA, QL), and guidance to check the plan's drug list; intended for providers prescribing medications to plan members.

Policy Summary

PayerCentene

PolicyFormulary drug coverage and alternatives (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when a listed drug shows 'PA' and verify any quantity limits (QL) or preferred alternatives on the plan formulary before prescribing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

40,000+drugs covered (stated breadth)

multipleformulary restrictions shown

1document date reference

Formulary Coverage & Restrictions

Formulary coverage with restrictions

Coverage and restrictions are indicated per drug entry; coverage decisions depend on the formulary status and any listed restriction (e.g., PA, QL).

Formulary alternative guidance: When a drug is listed as 'not covered', the document provides one or more formulary alternatives; coverage of the alternative is subject to any listed restriction (e.g., PA, QL).

Providers should verify coverage and restrictions on the official drug list.

Examples by drug: Specific entries show the formulary status and restrictions for individual drugs, for example: - NovoLog: Drug(s) covered on the formulary = None; Formulary restrictions = NovoLog. - Tresiba: Drug(s) covered on the formulary = Insulin Degludec**; Formulary restrictions = Tresiba. - Repatha: Drug(s) covered on the formulary = Praluent; Formulary restrictions = PA. - Forteo: Drug(s) covered on the formulary = Teriparatide 620mcg/2.48ml; Formulary restrictions = PA, QL.

See drug-specific rows for full list.

Preferred Alternatives and Step Recommendations

Policy Summary

PayerCentene

PolicyFormulary drug coverage and alternatives (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when a listed drug shows 'PA' and verify any quantity limits (QL) or preferred alternatives on the plan formulary before prescribing.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Preferred alternatives / step recommendations

When a non-formulary product is listed, try the indicated formulary alternatives first; check for PA or QL before prescribing the non-formulary product.

Preferred alternatives / step recommendations: Provider should consider the listed formulary alternative(s) for a non-covered drug and verify any prior authorization (PA) or quantity limit (QL) requirements before prescribing the non-formulary product.

Per formulary guidance; alternatives are suggestions and may not be right for every patient.

Examples of step recommendations: Examples include: Victoza → Mounjaro, Ozempic, Trulicity, Rybelsus; Advair Diskus / Wixela Inhub → Fluticasone‑Salmeterol Diskus**, Breo Ellipta; Insulin entries showing Semglee, Lantus, Basaglar as formulary relationships.

If alternatives are tried or are contraindicated, prior authorization may be required for the non-formulary product.

Step Therapy and Alternative Agents

Non‑formulary / Listed Product	Formulary Alternative(s)	Restriction on Alternative
NovoLog	None	NovoLog (formulary restriction noted)
Fiasp / Humalog (Insulin Lispro)	(no formulary product listed)	Fiasp (formulary restriction noted)
NovoLog mix 70/30	None	NovoLog mix 70/30 (formulary restriction noted)
Insulin Glargine‑yfgn pen	Semglee (yfgn); Lantus; Basaglar; KwikPen; Levemire	Semglee; Lantus; Basaglar; KwikPen; Levemire (formulary relationships noted)
Toujeo	(no formulary product listed)	Toujeo (formulary restriction noted)
Tresiba	Insulin Degludec**	Tresiba (formulary restriction noted)
Victoza	Mounjaro; Ozempic; Trulicity; Rybelsus	(no specific restriction listed for alternatives)
Advair Diskus / Wixela Inhub	Fluticasone‑Salmeterol Diskus**; Breo Ellipta	QL (quantity limit) applies
Advair HFA	(formulary alternatives include Fluticasone‑Salmeterol Diskus; Breo Ellipta; Advair HFA)	QL (quantity limit) applies
Symbicort / Dulera / Pulmicort / Flovent	Fluticasone‑Salmeterol Diskus; Breo Ellipta; Advair HFA; Arnuity Ellipta	QL (quantity limit) applies
Levalbuterol HFA	Albuterol HFA; Ventolin HFA	QL (quantity limit) applies
Spiriva (HandiHaler / Respimat)	Incruse Ellipta	QL (quantity limit) applies
Gemtesa (Fesoterodine ER)	Tolterodine IR/ER; Solifenacin; Oxybutynin ER; Myrbetriq; Oxybutynin IR	QL for some entries; one entry noted as None
Silodosin	Tamsulosin; Alfuzosin ER; Finasteride; Dutasteride; Dutasteride‑Tamsulosin	Some entries QL; some entries none
Repatha	Praluent	PA (prior authorization) applies

Quantity Limits

Quantity Limit (QL) summary by drug

Drugs with QL notedMultiple specific drug rows indicate 'Formulary restrictions = QL' (e.g., Advair Diskus/Wixela Inhub; Symbicort; Dulera; Pulmicort/Flovent; Levalbuterol HFA; Spiriva products; Gemtesa; Cyclosporine 0.05% eye drops; Forteo).

Typical QL scopeQuantity limits apply to the allowed quantity or refill frequency for the listed drug (per-month limits implied by policy's QL designation).

Examples of QL-marked alternativesFormulary alternatives for QL drugs include Fluticasone-Salmeterol Diskus**, Breo Ellipta, Advair HFA, Incruse Ellipta, Tolterodine IR/ER, Solifenacin, Oxybutynin ER, Myrbetriq.

Drugs with both PA and QLForteo is explicitly listed with both PA and QL restrictions.

Action for providersVerify any quantity limits on the plan's official drug list before prescribing; requests exceeding the QL may be denied or require prior authorization/documentation.

Actions Required by Providers

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required for select formulary drugs. Providers must obtain PA from Centene before the plan will cover these drugs. Failure to secure an approved PA may result in claim denial or delayed therapy.

Check Centene's PA criteria and submit complete supporting clinical documentation with the request.
Obtain PA prior to dispensing or administration whenever the formulary entry indicates “PA.”

Denial Risk

Formulary Restrictions Include PA and QL

Formulary restrictions frequently include prior authorization (PA) and quantity limits (QL). Requests that do not meet these restrictions may be denied. Ensure documentation demonstrates medical necessity and addresses the specific restriction criteria.

If a formulary entry lists PA or QL, include documentation such as diagnosis, prior therapies, treatment response, and justification for the requested dose/quantity.
Requests that omit required documentation or fail to meet stated criteria risk denial and may require appeal with additional records.

Note

Check the Plan Formulary

Providers should verify coverage and any restrictions by checking the plan's formulary (drug list) before prescribing or dispensing. The formulary is the authoritative source for covered products, preferred alternatives, and restriction flags.

Use the Centene/plan formulary lookup tools or provider portal to confirm coverage, PA, QL, and step-therapy requirements for the specific drug and member.
Formulary information can change; confirm coverage and restrictions at the time of prescribing and prior to filling the prescription.

Step Therapy

Formulary Entries Show Preferred Alternatives

Formulary entries identify preferred or interchangeable alternatives for drugs not covered on the formulary. Providers should evaluate listed formulary alternatives and consider step-therapy options before submitting non‑formulary or override requests.

When an alternative with the same active ingredient is listed (e.g., marked with **), members with an active prescription may be able to receive that alternative without a new prescription.
Try listed preferred alternatives or follow the step-therapy pathway noted on the formulary prior to requesting a non‑formulary drug or PA for an uncovered product.

Key Terms

Prior Authorization (PA)

DefinitionPrior authorization (PA) — a formulary restriction requiring approval before coverage is granted for the specified drug.

When requiredCertain drugs listed in this guide (e.g., Repatha; Procrit; Forteo; Xeljanz/Xeljanz XR) have 'Formulary restrictions = PA' indicating PA must be obtained prior to coverage.

Provider responsibilityProviders should submit documentation to support medical necessity when requesting PA and check the plan's drug list for PA requirements and processes.

Effect of missing PARequests for drugs requiring PA that do not meet PA requirements may be denied until approval is obtained.

Quantity Limit (QL)

DefinitionQuantity limit (QL) — a formulary restriction that limits the allowed quantity or refill frequency for a drug (indicated in drug rows as 'Formulary restrictions = QL').

Scope in this documentMultiple formulary entries are marked 'QL' to show where quantity restrictions apply (examples: inhaled corticosteroid/combination products, levalbuterol HFA, Spiriva products, Gemtesa, cyclosporine ophthalmic).

Provider actionCheck the plan's official drug list for the exact numeric limit and renewal timing before prescribing; exceeding the stated QL may require PA or will be denied.

Instances without QLSome alternatives and drugs in the guide are listed with 'Formulary restrictions = None', indicating no quantity limit is shown for those entries (e.g., Omega-3 Acid Ethyl Esters/Vascepa).

Policy Background

This Formulary Alternative Guide lists drugs that are not covered by the Plan alongside one or more formulary alternatives that are covered. It is intended to help prescribers identify covered options when a patient’s current medication is not on the formulary and to reduce the likelihood of a coverage denial by selecting a covered product where appropriate. The guide is administrative in nature and does not provide clinical treatment algorithms; providers should use clinical judgment when selecting an alternative and confirm suitability for the patient.

Use this guide when a prescribed brand or product is identified as “not covered” on the Plan’s drug list. The document highlights when alternatives are available and flags any formulary restrictions that apply to either the non‑formulary product or the alternative (for example, PA = prior authorization, QL = quantity limit). Providers should verify coverage and any restrictions on the Plan’s official formulary (drug list) before prescribing or dispensing.

When a non‑formulary product is listed, the expectation is to consider the listed formulary alternative(s) first. If an alternative is selected, check for any PA or QL noted for that agent; where PA or other restrictions apply, obtain required documentation or prior authorization per the Plan’s processes to avoid claim denials. The guide notes that the Plan covers more than 40,000 drugs overall and that the information is current as of the date shown in the document but may change, so providers should recheck the drug list for updates.