What is covered by the pharmacy
- Prescriptions drugs and over the counter (OTC) items approved
by the U.S. Food and Drug Administration (FDA). Not every OTC item
is covered; only those listed on the OTC Drug Formulary or the
Pharmacy Supplements Formulary are covered.
Note: HIP, Hoosier
Healthwise, and Hoosier Care Connect members must check with their
managed care entity to find out what pharmacy benefits are
- Self-injectable drugs (including insulin)
Note: You will be able
to also get needles, syringes, blood glucose monitors, test strips,
lancets, and glucose urine testing strips at your
- Drugs to help you quit smoking
What is not
- Medications that do not have an FDA-approved use
- Medications that are not medically necessary
- Experimental or investigational medications
- Medications to help you get pregnant
- Medications used for weight loss
- Cosmetic or hair-growth medications
- OTC medications not on the OTC Drug Formulary
Note: OTC items are not covered for any Hoosier
Healthwise Package C member.
Over the Counter Drug
Your pharmacist will give you generic
drugs when your doctor has okayed them. Generic drugs are as good
as brand name drugs and are less costly to the Indiana Medicaid
Program. Generic substitution under the program is required (refer
to Preferred Drug List for exceptions), as set out by statute at
Indiana Code (IC) 16-42-22-10. Generic drugs must be
dispensed when available. If generic drugs are not available, brand
name drugs may be dispensed. Brand name drugs may also be
dispensed, even if generic drugs are available, if Indiana Medicaid
determines the brand name drugs are less costly to the Indiana
Medicaid program. Generic and preferred drugs must be used when
available for your medical condition unless your physician provides
a medical reason that you must use a different drug.
Preferred Drug List (PDL)
Your pharmacy benefit has a Preferred Drug List or PDL. The PDL
shows some of the drugs covered under the pharmacy benefit. A team
of doctors and pharmacists update this list four times a year.
Updating this list ensures that the drugs are safe and useful for
you and cost effective for the Indiana Medicaid program. Drugs in
classes on the PDL are either preferred or nonpreferred; preferred
drugs typically do not require prior authorization, whereas
nonpreferred drugs generally do require prior authorization. Drugs
that are not on the PDL are covered by the Indiana Medicaid program
if they are not listed under "What Is Not Covered?". The PDL has
- names of preferred and nonpreferred drugs
- limits on the amount of a drug you can receive
You may need a drug that requires prior authorization. In this
case, your doctor will need to provide information about your
health, and then a decision will be made about whether or not
Indiana Medicaid can pay for the drug. This is important for
- You may need tests or help with a drug.
- You may be able to take a different drug.
Your doctor must submit a prior authorization request if:
- A drug is listed as nonpreferred on the PDL, or if certain
conditions need to be met prior to you receiving the drug.
- You are getting more drug that what is usually expected.
- There are other drugs that should be tried first.
For drugs that require prior authorization, you may get up to a
72 hour supply while waiting for the decision. The prior
authorization decision will be made within 24 hours of receipt of
the request (not including Sunday or some holidays), and your
doctor will be notified of the decision.
Your Appeal Rights
If a prior authorization request is denied, your provider can
appeal. See the Pharmacy Member Handbook for more