What are the drug copayments for pharmacy claims paid by
A $3 co-payment is required for legend and non-legend covered
drugs in accordance with IC 12-15-6
405 IAC 5-24-7.
What are the days supply limits on maintenance and
Maintenance drugs have a 100 days supply limit while
non-maintenance drugs have a 34 days supply limit.
What are the guidelines for coverage of drugs for Indiana
Indiana Medicaid covers drugs in accordance with the IHCP
rule 405 IAC 5-24-3, which is as
405 IAC 5-24-3 Coverage of legend drugs
IC 12-15-21-2 Affected: IC
IC 12-15 Sec. 3. (a) A legend drug is covered by
Indiana Medicaid if the drug is: approved by the
United States Food and Drug Administration; not
designated by the Health Care Financing Administration (HCFA) as
less than effective, or identical, related, or similar to a less
than effective drug; subject to the terms of a rebate
agreement between the drug's manufacturer and the HCFA; and
not specifically excluded from coverage by Indiana
Medicaid. (b) The following are not covered by Indiana
Anorectics or any agent used to promote weight
Topical minoxidil preparations.
Fertility enhancement drugs.
Drugs when prescribed solely or primarily for cosmetic
Who can I call if I have questions about the Indiana
Medicaid pharmacy benefit?
You may call HP Enterprise Services Member Services Hotline
What is a Preferred Drug List (PDL) and how are drugs
placed on the PDL?
PDL is an acronym for preferred drug list, which is a portion
of all drugs covered under pharmacy benefit. A subcommittee of the
Drug Utilization Review (DUR) Board, the Therapeutics Committee,
advises and makes recommendations to the Board on the content of
the PDL. Drugs in classes that are subject to the PDL are
designated as either preferred or
preferred drugs typically do not require
prior authorization, whereas non-preferred
drugs generally do require prior authorization.
Where is the Preferred Drug List (PDL)
The PDL can be found on the provider portion of
this site at www.indianapbm.com
under the Pharmacy Services.
What drugs require prior authorization (PA)?
In general, drugs that are categorized as non-preferred
require prior authorization.
Note: There are exceptions to
this rule. Some preferred drugs may require prior
authorization. Also, claims with excessive quantities, Step
Therapy requirements, Brand Medically Necessary requirements, and
drugs with age limitations may be subject to prior
What is the Preferred Drug List (PDL) status of mental
In accordance with Indiana law, all antianxiety,
antidepressant, antipsychotic, and
"cross indicated" drugs are considered as being
preferred. Drugs that are (1) classified in a central nervous
system drug category or classification (according to Drug Facts and
Comparisons) created after March 12, 2002, and (2) prescribed for
the treatment of a mental illness (as defined by the most recent
publication of the American Psychiatric Association's Diagnostic
and Statistical Manual of Mental Disorders) are also considered as
I cannot find certain drugs listed on the Preferred Drug
List (PDL); what does this mean?
Drugs that are not listed on the PDL are covered by the
Indiana Medicaid Program, to the extent they are not specified by
405 IAC 5-24-3 as non-covered.
How quickly will a prior authorization (PA) request be
approved or denied?
The PA request must be approved or denied within 24 hours of
receipt of the request.
Does the Indiana Medicaid fee-for-service pharmacy
program have a limit on the number of prescriptions or number of
branded drugs members can receive each month?
Where can I find the OTC Drug Formulary?
How do I appeal a denial of a prior
If a prior authorization request is denied, your
provider can ask for a review of a denial
decision. Your provider must submit a written request
for Administrative Review within seven business days
of the receipt of notification of the denial. Your provider must
follow the process as outlined in the Provider Manual.
Where can I find information about blood glucose monitors and
diabetic test strips?
Please see the member letter that
outlines the benefit for blood glucose monitors and diabetic