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
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 no listed under
Non-covered services. The PDL has information about:
- names of preferred and nonpreferred drugs
- limits on the amount of a drug you can receive
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.
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.