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Covered Medications

What is covered by the pharmacy benefit?

  • 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 are covered.

Note: For HIP members only OTC items listed on the PDL and OTC Drug Formulary are covered.

  • 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 pharmacy.

  • Drugs to help you quit smoking

What is not covered?

  • 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.

Generic Drugs

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 information about:

  • names of preferred and nonpreferred drugs
  • limits on the amount of a drug you can receive

Prior Authorization

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 several reasons:

  • 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 information.