MHS covers certain prescription drugs and over-the-counter drugs when written on a prescription, by a practitioner in the MHS provider network. The pharmacy program does not cover all drugs. Some require prior authorization. Some drugs have limitations on age, dosage, or maximum quantities.
The Preferred Drug List (PDL) is the list of drugs covered by MHS. The PDL applies to drugs that members receive at retail pharmacies. The MHS Pharmacy and Therapeutics Committee checks the PDL quarterly to make sure the list includes medicines that are right for our members, as well as cost-effective. The Committee includes the MHS Medical Director, MHS Pharmacy Director, and several Indiana physicians, pharmacists, and specialists.
These prescription drugs are not covered:
- Over-the-counter (OTC) medicines (unless specified on the formulary or PDL list)
- Drugs used to get pregnant
- Experimental or investigational drugs
- Drugs for cosmetic reasons
- Drugs for weight loss
- Drugs for hair growth
- Drugs to treat erectile dysfunction
Your pharmacist will give you generic drugs when your doctor has approved them. All generic drugs approved by FDA have the same high quality, strength, purity, and stability as brand-name drugs. If generics are not available, you may be given brand-name drugs. Generic and preferred drugs must be used when available for your medical condition unless your doctor provides a medical reason you must use a different drug.
Some OTC drugs are covered by your PDL. Only OTC drugs that are listed on your PDL may be covered. OTC medications are only covered when written by your physician on a prescription.
Some medications listed on the PDL may require a prior authorization. The prior authorization request should be submitted by the doctor or pharmacist on the Medication Prior Authorization Form. Directions on how to submit are included on this form. You can find a copy of the Medication Prior Authorization Form on the Provider Forms page.
MHS will cover medication if it is determined that:
- There is a medical reason the member needs the specific medication.
- Depending on the medication, other medications on the PDL have not worked.
All MHS members must use a pharmacy in the Indiana Medicaid network, including mail-order pharmacies.
You can find an in-network pharmacy by using the Find a Provider tool.
To find an in-network pharmacy:
- Click on Find a Provider.
- Click Start Your Search. A new window will open.
- Enter your zip code, and choose Healthy Indiana Plan as your plan.
- Click Detailed Search.
- In the Type of Provider box, choose Pharmacy.
- Click Search.
Always present your member ID card to the pharmacy every time you fill or pick up an order. Do not wait until you are out of a drug to request a refill. Please call your doctor or pharmacy a few days before you run out.
Specialty drugs are drugs that are usually used to treat complex medical conditions and have unique storage and handling instructions. Often these medications are injectable and high cost. These medications have to be filled at our preferred specialty pharmacy. These drugs are marked on the PDL with the letter “S”.
- Members in the HIP Basic and HIP State Plan Basic plans will need to pay $4 for preferred drugs and $8 for non-preferred drugs unless you have an excluded condition.
- HIP members in the Plus or State Plus plans do not pay copays for prescriptions.
- Excluded conditions include members who are pregnant, of Native American descent, less than 18 years of age or have already met their 5% cost sharing max. These members will be exempt from copays.
- Medications for family planning will be exempt from copays
|Plan Type||Generic/Preferred Drug||Non-Preferred Drug|
|HIP State Basic||$4.00||$8.00|
|HIP Plus, State Plus||No Cost||No Cost|