Does Ambetter from Coordinated Care limit or exclude certain drugs my health care provider may prescribe, or encourage substitutions for some drugs?

According to the Affordable Care Act (ACA), we cannot exclude any drug. Prescription drugs not available on the 2024 Formulary/Prescription Drug List (PDF) can be reviewed through an exception process.

There are also limitations on quantities for prescribed drugs. Your provider would need to get prior authorization for certain medications. Generic drugs are preferred.

When can Ambetter from Coordinated Care change the Formulary? If a change occurs, will I have to pay more to use a drug I had been using?

We review the Formulary on a quarterly basis to ensure that the most up-to-date prescription drugs are listed. Any changes are then implemented 30 days after the quarterly pharmacy committee review. Changes that negatively impact the cost of your prescription will only be implemented once a year at the start of a new benefit year.  You will not have to worry about changes in prescription costs for Formulary updates made during the year. Cost neutral and cost lowering updates will be implemented quarterly.

What should I do if I want to see a change in limitations, exclusions, substitutions or cost increases for drugs specified in my Ambetter from Coordinated Care plan?

You may submit your concerns about any changes through the Grievance and Appeals process. Please click here to learn more.

How much do I have to pay to get a prescription filled?

Your prescription costs will depend on your selected Ambetter from Coordinated Care plan. Please review your Schedule of Benefits located under your online Member Account to see specifics on prescription costs for your plan.

Do I have to use certain pharmacies to pay the least out of pocket?

No, you may use any pharmacy in our network. To find a pharmacy in our network use the Ambetter from Coordinated Care Provider Directory.

How many days’ supply of medications can I get without paying another co-pay or other repeating charge?

You may request a 30-day supply of your medications.

What other pharmacy services does Ambetter from Coordinated Care cover?

For a complete list of covered pharmacy benefits, please review your Evidence of Coverage (EOC) available under the secure Member Account.

Don’t have a secure online Member account? Sign up for one here.