The Ambetter Health Prescription Drug List (PDL) or 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.

The PDL/Formulary applies to drugs members can receive at network pharmacies. The Ambetter Health PDL/Formulary is continually evaluated by the Ambetter Health Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of Medical Directors, Pharmacy Directors, and physicians, pharmacists, and other healthcare professionals.

Ambetter Health works with Centene Pharmacy Services to process pharmacy claims for prescribed drugs. Some drugs on the Ambetter Health PDL/Formulary may require prior authorization (PA), Centene Pharmacy Services is responsible for administering this process. Express Scripts® is our Pharmacy Benefit Manager.

AcariaHealth is the preferred specialty pharmacy provider of Ambetter Health. Select specialty drugs, such as biopharmaceuticals and injectables, require PA to be approved for payment by Ambetter Health.

AcariaHealth provides the following services:

• A dedicated, multilingual team available 24 hours a day, 7 days a week to meet the unique needs of each patient
• Disease-specific product education and training Customized treatment programs and compliance monitoring
• Prior authorization support
• Timely delivery to your office or the patient’s home, as requested

Drug or disease state specific enrollment forms can be found on the Ambetter Health website.

Drugs may be dispensed up to a maximum of thirty-one (31) days supply for each new prescription or refill. Select chronic medications can be dispensed up to a 93 day (3 month) supply. A total of 80% of the days supply or 25 days must have elapsed before the prescription can be refilled for non-controlled-substance PDL/Formulary drugs. A total of 90% of the days supply must have elapsed before the prescription can be refilled for controlled substances and narcotic PDL/Formulary drugs.  

The health and safety the member is a priority for Ambetter Health. One of the ways we address member safety is through point-of sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on FDA recommendations and promote safe and effective medication utilization.

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.

For more about prior authorizations, see the “Prior Authorization” section in your Evidence of Coverage or Major Medical Expense Policy.

Ambetter Health will cover the medication if it is determined that:

1. There is a medical reason the member needs the specific medication.
2. Depending on the medication, other medications on the PDL/Formulary have not worked.

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 information about prior authorizations, see the “Prior Authorization” section in your Major Medical Expense Policy or Evidence of Coverage.

• EPO - 2025 Major Medical Expense Policy
• HMO – 2025 Evidence of Coverage

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 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. 

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.

Some drugs on the Ambetter Health Formulary/Prescription Drug List (PDL) may have age limits. These are set for certain drugs based on FDA-approved labeling, safety concerns, and quality standards of care.

Some medications on the Ambetter Health PDL/Formulary may be limited to one gender. These limits are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Gender limits align with current FDA alerts for the appropriate use of pharmaceuticals.

If the member requires a medication that does not appear on the PDL/Formulary, the member’s practitioner can make a medical formulary exception request for the medication. It is anticipated that such exceptions will be rare as the PDL/Formulary medications are appropriate to treat the vast majority of medical conditions.

For a formulary exception request Ambetter Health requires:

• Documentation of failure of at least two PDL/Formulary agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or
• Documented intolerance or contraindication to at least two PDL/Formulary agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or
• Documented clinical history or presentation where the patient is not a candidate for any of the PDL/Formulary agents for the indication.

These requests are reviewed by a licensed clinical pharmacist using the criteria established by the Ambetter Health P&T Committee. If the request is approved, Centene Pharmacy Services notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, Ambetter Health will notify the member and their practitioner of alternatives and provide information regarding the appeal process.

Ambetter Health reviews new drugs for safety and effectiveness before adding them to the PDL/Formulary. During this period, access to these medications will be considered through the PA review process. If Ambetter Health does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process.

Ambetter Health covers a variety of OTC medications. These medications can be found throughout the Ambetter Health PDL/Formulary. Ambetter Health covers OTC products listed in the PDL/Formulary if the member has a prescription from a licensed practitioner that meets all the legal requirements for a prescription.

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.

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.