Pharmacy FAQ

What are the drug copayments for pharmacy claims paid by Indiana Medicaid?

A $3 co-payment is required for legend and non-legend covered drugs in accordance with IC 12-15-6 and 405 IAC 5-24-7.

What are the days supply limits on maintenance and non-maintenance drugs?

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 Medicaid?

Indiana Medicaid covers drugs in accordance with the IHCP rule 405 IAC 5-24-3, which is as follows:

405 IAC 5-24-3 Coverage of legend drugs

Authority: IC 12-8-6-5; IC 12-15-1-10; IC 12-15-21-2 Affected: IC 12-13-7-3; 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 Medicaid:

Anorectics or any agent used to promote weight loss.

Topical minoxidil preparations.

Fertility enhancement drugs.

Drugs when prescribed solely or primarily for cosmetic purposes.

Who can I call if I have questions about the Indiana Medicaid pharmacy benefit?

You may call OptumRx's Clinical/Technical Help Desk at 1-855-577-6317.

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 non-preferred; preferred drugs typically do not require prior authorization, whereas non-preferred drugs generally do require prior authorization.

Where is the Preferred Drug List (PDL) located?

You can find the PDL by clicking on the Preferred Drug List link.

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 authorization.

What is the Preferred Drug List (PDL) status of mental health drugs?

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 being preferred.

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 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?

You can find the OTC Drug Formulary by clicking on OTC Drug Formulary.

How do I appeal a denial of a prior authorization?

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 test strips.