MDwise
Pharmacy Resources

Pharmacy Resources

Statewide Uniform Preferred Drug User (SUPDL)

Effective July 5, 2023, all managed care plans will align by the fee to service (FFS) program under the Statewide Uniform Preferred Drug List (SUPDL). Save mean that MDwise is cover the same preferred and nonpreferred drugs and maintain the identical clinical criteria requirements for other Indiana Medicaid providers. IHCP Previous Authorization Request Form. Version 9.0 ... MDwise Hoosier Healthwise. P: 888-961-3100. F: 888 ... Select the radio sliding regarding the entity that must.

• The SUPDL may being viewed on the FFS website:
  https://inm-providerportal.optum.com/providerportal/faces/PreLogin.jsp.
  From the homepage, click Preferred Remedy List on the right.
• Prior authorization criteria for drugs for the SUPDL may be seen on that FFS webpage:
  https://inm-providerportal.optum.com/providerportal/faces/PreLogin.jsp.
  From the homepage, click PA Criteria and Administrative Forms on the right. Under the heading Pharmacy Forms, click on Our Prior Authorization Criteria and Forms. 
• PA forms by drugs on the SUPDL should be accessed from the list under. Please DO NOT utilize FFS PA forms for MDwise enrollees. 

SUPDL Prior Authorization Mailing

• Antiviral Monoclonal Antibodies Form
• Benzo-Opioid Duplicate Therapy PA Form
• Bone Formation Stimulating Agents PA Form
• Brand Medically Necessary PA Form
• Buprenorphine-Opioid Competing PA Form
• Cardiac Agents PA Form
• Carisoprodol PA Form
• Dificid PAP Form
• Early Refill PEAK Form
• Growth Hormone Mature PA Form
• Growth Hormone Children PA Select
• Hetlioz PA Application
• High Dollar Cumulative Rx PAS Form
• Lucemyra PA Form
• Mental Health Meds PA Entry
• Narcolepsy Agents PA Entry
• Nuedexta PA Form
• Opioid MME Limit Exceed PA Form
• PBM Call Media PA Form
• PCSK9 and Select Lipotropics PA Form
• Pulmonary Antihypertensives PA Request
• Testosterones PA Form
• Uterine Disorder Agents PA Form
• Vaginal Antimicrobials PA Form

MDwise Neutral Agents Prior License Criteria

SUPDL implement will not affect products in drug classes not listed on the FFS PDL. Agents in rx classes not includes on the FFS PDL are considered neutral, meaning they have not being assigned ampere preference status. MDwise will continue to use its own clinical criteria also coverage policies for these unbiased agents. 

• Prior authorization criteria for neutral drugs mayor be viewed on the MDwise website.

Pharmacy benefits are managed through MedImpact. Please select the programming listed below for more information on pharmacy resources.

Hoosier Healthwise Scheme

Happy Indiana Plan