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
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
- 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