Pharmacy Benefits

Overview

When you need drugs or over-the-counter items, your doctor will write you a prescription. Your doctor will then contact your pharmacy, or you can take the prescription to your pharmacy to receive your medication(s). You must use a pharmacy that accepts Indiana Medicaid and that is part of your health plan's network. Each health plan uses specific large chain pharmacies, and some require use a mail order or specialty pharmacy for certain medications.

Tip: Always remember to present your Hoosier Health, Healthy Indiana Plan (HIP), Hoosier Care Connect or Hoosier Healthwise ID Card to your pharmacy provider.

Tip: Do not wait until you are out of medicine to request a refill. Please call your doctor or pharmacy a few days prior to being out of your medication.

Covered medications

The following medications are covered by Indiana Medicaid:

Most prescriptions drugs approved by the U.S. Food and Drug Administration (FDA)
Over the counter (OTC) items listed on the OTC Drug, Pharmacy Supplements, or OTC Contraception Formulary.
Self-injectable drugs, including insulin (You will also be able to get needles, syringes, diabetes glucose monitoring products, lancets, and glucose urine testing strips, as well as spacers for inhaled medicines at your pharmacy.)
Drugs to help you quit smoking

The following medications are not covered by Indiana Medicaid:

Medications made by manufacturers that do not participate in the Medicaid program
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

Tip: HIP, Hoosier Healthwise, and Hoosier Care Connect members must check with their health plan to find out what pharmacy benefits are covered.

Generic Drugs

In most cases, your pharmacy will give you generic drugs if your doctor's prescription allows. Indiana law requires generic drugs be dispensed when available, with some exceptions. Generic drugs are as safe and effective as brand name drugs but are typically less costly. 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. 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 (PDL). The PDL shows drugs covered under the pharmacy benefit that have a preferred or nonpreferred status. It does not include all drugs covered by Indiana Medicaid. A team of doctors and pharmacists update the PDL four times a year to ensure that the drugs are safe and cost effective for the Indiana Medicaid program.

Drugs listed on the PDL are either preferred or nonpreferred; preferred drugs typically do not require prior authorization, whereas nonpreferred drugs generally do require prior authorization.

Prior Authorization

You may need a drug that requires prior authorization. In this case, your doctor will need to provide information about your health condition, and then a decision will be made about whether or not the medication is appropriate.

Your doctor must submit a prior authorization request if:

A drug is listed as nonpreferred on the PDL
Certain conditions must be met prior to you receiving the drug.
Your prescription is beyond the limit typically allowed.
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 Sundays or some holidays), and your doctor will be notified of the decision.

If a prior authorization request is denied, you can appeal. To learn more about your appeal rights, you can refer to the Member Appeals webpage.

Days' Supply Limit

Drugs you take for a long time (often called maintenance drugs) have higher supply limits, while drugs you take for a shorter time (non-maintenance drugs) are likely to have a 30-34 days' supply limit. Maintenance drugs are taken for illnesses such as asthma, diabetes, and high blood pressure. Non-maintenance drugs are generally taken for short term illness such as a cold, flu or an infection.

Drug Copayments

You may have to pay something for each of your drugs; this amount is called a copay. In some instances, copays cannot be charged, such as:

Prescriptions for members under the age of 18
Prescriptions related to a pregnancy
Prescriptions related to family planning (birth control and preventive supplies)
Prescriptions while in an emergency room or nursing home
Prescriptions while in a hospital
Prescriptions dispensed as an emergency supply

To find more information on the copay amounts, please go to the Indiana Medicaid Covered Services webpage.

Questions About Your Pharmacy Benefits

If you need help finding a pharmacy or have questions about your pharmacy benefits, contact either your health plan or OptumRx's Clinical/Technical Help Desk. You can find the contact information on the Contact Us page.