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Pharmacy Benefits

Indiana Health Coverage Programs (IHCP) pharmacy benefits are administered as follows:

  • The individual managed care entities (MCEs) serving Healthy Indiana Plan (HIP), Hoosier Care Connect and Hoosier Healthwise members contract with designated pharmacy benefit managers (PBMs) to manage the pharmacy benefits and process pharmacy claims for their enrolled members under the IHCP managed care delivery system.
  • Optum Rx is the PBM for members enrolled in Traditional Medicaid and other fee-for-service (FFS) programs, as well as for pharmacy services that are carved out of the managed care delivery system.

Pharmacy benefit information, including Preferred Drug Lists (PDLs) and drug prior authorization (PA) criteria, for each PBM is available from the links provided on the Pharmacy Services page of this website.

Additional information about pharmacy services is also available from the PBM websites, including information about:

  • Drug Utilization Review (DUR) Board
  • Mental Health Quality Advisory Committee (MHQAC)
  • Preferred Diabetes Supply List (PDSL)
  • Medicare prescription drug coverage
  • Therapeutics Committee (Optum Rx)
  • State Maximum Allowable Cost (SMAC) program (Optum Rx)

You can find FFS and managed care pharmacy contact information, including contacts for pharmacy prior authorization and pharmacy claims, on the IHCP Quick Reference Guide.

The Pharmacy Services provider reference module outlines FFS pharmacy policies and procedures.

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