This is the sharing of costs under your insurance plan that you pay out of your pocket. This includes items such as copays, deductibles, and coinsurance. Cost sharing does not include premiums, balance billing amounts to non-network providers, or the cost for non-covered services.

A copay is the set amount of money you pay at the time of certain medical services, such as doctor visits or picking up prescriptions. The copay amount for your prescriptions may vary depending on the tier of your prescription coverage.

A formulary is a list of generic and brand-name drugs covered by your health plan. They are listed in tiers based on the drug type. Drugs in lower tiers will cost less than drugs in higher tiers.

A deductible is a set dollar amount you are responsible for before your health plan will start paying for health services. Drugs may or may not be subject to the deductible, based on the tier.

If the tier is not subject to the deductible, you will pay only the cost-share for that drug tier. If the tier is subject to the deductible, you will first have to pay the deductible before you start paying the cost-share of that tier. 

A member can have prescriptions filled at an Ambetter Health network pharmacy. If the member decides to have a prescription filled at a network pharmacy, they can locate a pharmacy near them by contacting Ambetter Health Member Services at 1-800-442-1623 (TTY 711).

A member can also use the Find a Provider Tool to locate in-network pharmacies. At the pharmacy, the member will need to provide the pharmacist with the prescription and their Ambetter Health ID card.

Generic drugs have the same active ingredient and work the same as brand-name drugs.

When generic drugs are available, the brand-name drug will not be covered without Ambetter Health authorization. If the member or their physician feels a brand-name drug is medically necessary, the physician requests the drug using the prior authorization process.

We will cover the brand-name drug according to our clinical guidelines if there is a medical reason the member needs the brand-name drug. If Ambetter Health does not grant authorization, we will notify the member and their physician and provide information regarding the appeal process.

Some drugs listed on the Formulary/Prescription Drug List (PDL) may need prior authorization. The information should be submitted by the physician or pharmacist to Centene Pharmacy Services on the Prior Authorization Request Form for Non-Specialty Drugs. The form should be faxed to Centene Pharmacy Services at 1-800-977-4170.

Authorization requests are reviewed by a licensed clinical pharmacist using the criteria set by the Ambetter Health Pharmacy and Therapeutics (P&T) Committee. If the request is approved, CPS Pharmacy Drug Utilization team notifies the physician by fax. If the clinical information does not meet the coverage criteria for the requested medication, Ambetter Health will notify the member and their physician of alternatives and provide information about the appeal process.

A provider can also submit a PA request through Cover My MedsExternal Link.

For more about prior authorizations, see the “Prior Authorization” section in your Evidence of Coverage. 

If your drug is not covered by our formulary, your provider can request a non-formulary exception request. Your provider can submit the non-formulary exception the same way as a regular prior authorization.

Some medications listed on the Ambetter Health Formulary/Prescription Drug List (PDL) may require specific medications to be used before the member can receive the step therapy medication. If Ambetter Health has a record that the required medication was tried first, the step therapy medications are automatically covered.

If Ambetter Health does not have a record that the required medication was tried, the member’s physician may be required to provide additional information. If authorization is not granted, Ambetter Health will notify the member and their physician and provide information regarding the appeal process.

Ambetter Health may limit how much of a certain medication a member can get at one time. If the physician feels the member has a medical reason for getting a greater amount, a prior authorization may be requested. If Ambetter Health does not grant prior authorization, we will notify the member and their physician and provide information about the appeal process.