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

• 2024 Formulary/Prescription Drug List (PDF)
  
• 2023 Formulary/Prescription Drug List (PDF)
  
• 2023 Formulary Changes (PDF)
• 90 Day Maintenance Drug List (PDF)
• Therapeutic Interchange List (Marketplace) (PDF)

PA Forms

• CoverMyMeds
  
• Prior Authorization Request Form for Non-Specialty Drugs (PDF)
• Prior Authorization Request Form for Specialty Medication or Buy and Bill (PDF)

Provider Educational Resources

Envolve Pharmacy Solutions provides quarterly educational outreach material to providers on common drug therapy and disease problems with the aim of improving prescribing and dispensing practices.

CVS Retail Pharmacies No Longer in network for 2022

Ambetter from Sunshine Health wants to make sure that our members receive the highest quality care at the lowest premium. One way we do this is by monitoring our pharmacy network performance.

To provide our members, your patients with the lowest possible premium for 2022, CVS retail pharmacies will no longer participate in our network as of January 1, 2022.

Additionally, Walgreens retail pharmacies will be the only in-network pharmacy for extended days’ supply prescriptions (those for 84 or more day supply). Members pay only 2.5 copays (save ½ a copay) when they fill eligible maintenance medications, 90 days at a time, at Walgreens starting January 1, 2022.

If your patients currently fill their prescriptions at CVS retail pharmacies, please send or call in their scripts to any in-network pharmacy. To help you locate an alternate in-network pharmacy for 2022, please refer to guide.ambetterhealth.com.

We value having you as an Ambetter from Sunshine Health provider and we hope this information allows you to make informed decisions about managing your patient’s health.

Prescription Drug Exception Request 

The member, the member’s designee or the member’s prescribing physician may request an exception to Our Prescription Drug requirements when:

1. The drug is not covered based on our formulary.
2. We are discontinuing coverage of the drug.
3. The drug, as requested, does not conform to the limitations and procedures under Our drug utilization management program such as step therapy, dosage limitations or therapeutic substitutions.

To request this exception the provider can utilize the regular PA request processes and forms available in our website. The provider should make sure to submit any information on previous approval of the drug for your patient or/and reason for requesting the exemption. A Medical Director, pharmacist, or other health care professionals who have appropriate clinical expertise in your patient’s condition will make a determination according to accepted medical practice. We will notify the member and the member’s prescribing physician of our decision within fifteen (15) calendar days or sooner, depending on the request.

If we do not approve the request, the member and the prescribing physician will receive detailed information about why the decision was made, as well as the process and time frame you should follow for submitting appeals.