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Indiana Medicaid Statewide Uniform Preferred Drug List (SUPDL)

WebEffective for FFS claims submitted on or after January 1, 2024. Effective for Managed Care claims submitted on or after January 15, 2024. V1.1

Actived: 6 days ago

URL: https://prdgov-rxadmin.optum.com/rxadmin/INM/20240101_INM_SUPDL(1)_Final.pdf

Indiana Medicaid Statewide Uniform Preferred Drug List (SUPDL)

WebEffective August 1, 2023 V1.1 Inclusion or reference to any given drug does not indicate market availability of the drug. Drugs that will be, or have been, withdrawn from the …

Category:  Health Go Health

Indiana Medicaid Preferred Drug List (PDL)

WebEffective August 1, 2023 V1.0 Inclusion or reference to any given drug does not indicate market availability of the drug. Drugs that will be, or have been, withdrawn from the …

Category:  Health Go Health

Indiana Medicaid Provider Portal New User Request

WebTo the best of my knowledge the information supplied in this document is true, accurate, and complete and is provided to OptumRx for the purpose of accessing …

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Provider Portal New User Request

WebI understand that my signature certifies that I am authorized to make binding decisions on behalf of the Provider/Facility listed above. Medicaid/PeachCare Provider Signature: …

Category:  Health Go Health

Nurtec ODT™, Qulipta™, Reyvow , Ubrelvy™ Prior …

WebThis document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI).

Category:  Health Go Health

Please note: All information below is required to process this …

WebPlease indicate the daily dosages and the quantity requested per prescription/fill/ or month and the duration (i.e., 3 capsules per day, 4 capsules per prescription/per 30 days).

Category:  Health Go Health

Indiana Health Coverage Programs (IHCP) Drug Coverage

WebEffective September 1, 2023 V1.0 Inclusion or reference to any given drug does not indicate market availability of the drug. Drugs that will be, or have been, withdrawn from the m

Category:  Health Go Health

201710 drug claim form

WebPLEASE PRINT CLEARLY Table A.19 Indiana Health Coverage Programs DRUG CLAIM FORM MEMBER NAME: LAST, FIRST PRESCRIBER NPI EMERGENCY PREG …

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Opioid Naïve Prior Authorization Request Form Member …

WebThis document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI).

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Hepatitis C Prior Authorization Request Form (Page 1 of 2)

WebThis document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI).

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Humira Prior Authorization Request Form (Page 1 of 2)

WebHumira Prior Authorization Request Form (Page 1 of 2) This document and others if attached contain information that is privileged, confidential and/or may contain protected …

Category:  Health Go Health

Sunosi Prior Authorization Request Form

WebThis document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI).

Category:  Health Go Health

Indiana Health Coverage Programs (IHCP) Pharmacy Benefit …

WebEffective January 1, 2007 Revised: May 25, 2018. Indiana Health Coverage Programs (IHCP) Pharmacy Benefit. Mental Health Medications

Category:  Health Go Health

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