We are committed to providing appropriate, high-quality, and cost-effective drug therapy to all Ambetter Health members. Use our Preferred Drug List to find more information on the drugs that Ambetter Health covers.

• 2025 Formulary/Prescription Drug List (PDF)
  
• 2025 Formulary Changes (PDF)
• 2024 Formulary/Prescription Drug List (PDF)
  
• CGM (Continuous Glucose Monitors) - FreeStyle Libre (Preferred)
• 90-Day Extended Supply Medications (PDF)

PA Forms

• CoverMyMeds
• Prior Authorization Request Form for Non-Specialty Drugs - Retail Pharmacy (PDF)
• Medical Benefit - Buy And Bill Request (PDF)

Evolent - Oncology

All oncology-related chemotherapeutic drugs and supportive agents will require prior authorization from Evolent before being administered in a physician’s office, outpatient hospital, or ambulatory setting. This process applies to both Medical Benefit (Buy and Bill Request) AND Pharmacy Services (Retail Pharmacy)

Pre-Approval Process

The requesting physician must complete an authorization request using one of the following methods:

• Log in to the Evolent Provider Web Portal.
• Call 1-888-999-7713 and select option 1, from 8 a.m. to 8 p.m. EST, Monday through Friday. General Evolent  Information.
• Evolent FAQ (PDF)