Pharmacy Policies
These pharmacy policies apply to our Indiana Medicaid plan(s).
Pharmacy policies offer guidance on determination of medical necessity coverage of pharmaceutical products. The coverage criteria are consistent with FDA-approved prescribing information, treatment guidelines and literature. The policies listed on this page are not all inclusive of all pharmaceutical products. New policies will be added as new pharmaceutical products become available or as needed. Existing policies are regularly reviewed and updated to reflect current treatment guidelines and prescribing information.
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
Current Pharmacy Policies
A
- Abecma (idecabtagene vicleucel)
- Actemra (tocilizumab)
- Acthar Gel (repository corticotropin injection)
- Adakveo (crizanlizumab-tmca)
- Aduhelm (aducanumab-avwa)
- Aimovig (erenumab-aooe)
- Ajovy (fremanezumab-vfrm)
- Aldurazyme (laronidase)
- Alpha-1 Proteinase Inhibitors
- Amondys 45 (casimersen)
- Apretude (cabotegravir extended-release)
- Aranesp (darbepoetin alfa)
- Arcalyst (Rilonacept)
- Aubagio (teriflunomide)
- Austedo (deutetrabenazine)
- Avastin (bevacizumab)
B
- Bafiertam (monomethyl fumarate)
- Benlysta (belimumab)
- Beovu (brolucizumab)
- Berinert (C1 esterase inhibitor (human))
- Bethkis (tobramycin inhalation solution)
- Bleeding Disorder Agents
- Botox (onabotulinumtoxinA)
- Breyanzi (lisocabtagene maraleucel)
- Brineura (cerliponase alfa)
- Bronchitol (mannitol)
- Bylvay (odevixibat)
C
- Cabenuva (cabotegravir/rilpivirine)
- Cablivi (caplacizumab-yhdp)
- Cayston (aztreonam inhalation solution)
- Cerdelga (eliglustat)
- Cimzia (certolizumab pegol)
- Cinqair (reslizumab)
- Cinryze (C1 esterase inhibitor (human))
- Cosentyx (secukinumab)
- Crysvita (burosumab-twza)
- Cysteamine (Procysbi, Cystagon, Cystaran, Cystadrops)
- Cytogam (cytomegalovirus immune globulin)
- Cytomegalovirus Immune Globulin Intravenous (Cytogam)
D
E
- Elaprase (idursulfase)
- Emflaza (deflazacort)
- Emgality (galcanezumab-gnlm)
- Empaveli (pegcetacoplan)
- Enbrel (etanercept)
- Enspryng (satralizumab-mwge)
- Entyvio (vedolizumab)
- ENZYME REPLACEMENT THERAPY (ERT) FOR GAUCHER DISEASE: Cerezyme (imiglucerase), Elelyso (taliglucerase alfa), Vpriv (velaglucerase alfa)
- Epidiolex (cannabidiol)
- Epogen (epoetin alfa)
- Esbriet (pirfenidone)
- Evenity (romosozumab-aqqg)
- Evkeeza (evinacumab-dgnb)
- Evrysdi (risdiplam)
- Exondys 51 (eteplirsen)
- Eylea (aflibercept)
F
G
H
I
- Ilaris (canakinumab)
- Ilumya (tildrakizumab-asmn)
- Iluvien (fluocinolone acetonide)
- Imbruvica (ibrutinib)
- Immune globulin (IVIG and SCIG)
- Inflectra (infliximab-dyyb)
- Ingrezza (valbenazine)
- Inhaled Prostacyclins for Pulmonary Arterial Hypertension: Tyvaso (treprostinil), Ventavis (iloprost)
- Injectable somatostatin analogs (First generation)
- Interferons for Multiple Sclerosis: Avonex (interferon beta-1a), Betaseron (interferon beta-1b), Extavia (interferon beta-1b), Plegridy (peginterferon beta-1a), Rebif (interferon beta-1a)
- Isturisa (osilodrostat)
J
K
- Kalbitor (ecallantide)
- Kalydeco (ivacaftor)
- Kanuma (sebelipase alfa)
- Kesimpta (ofatumumab)
- Kevzara (sarilumab)
- Kineret (anakinra)
- Kitabis Pak (tobramycin inhalation solution)
- Korlym (mifepristone)
- Korsuva (difelikefalin)
- Koselugo (selumetinib)
- Krystexxa (pegloticase)
- Kuvan (sapropterin)
- Kymriah (tisagenlecleucel)
L
M
N
O
- Ocrevus (ocrelizumab)
- Ofev (nintedanib)
- Olumiant (baricitinib)
- Oncology Treatment Regimen Review
- Onpattro (patisiran)
- Orencia (abatacept)
- Orfadin (nitisinone)
- Oriahnn (elagolix, estradiol, and norethindrone acetate; elagolix)
- Orilissa (elagolix)
- Orkambi (lumacaftor/ivacaftor)
- Orladeyo (berotralstat)
- Otezla (apremilast)
- Oxbryta (voxelotor)
- Oxervate (cenegermin-bkbj)
- Oxlumo (lumasiran)
- Ozurdex (dexamethasone)
P
Q
R
- Radicava (edaravone injection)
- Ravicti (glycerol phenylbuytyrate)
- Reblozyl (luspatercept-aamt)
- Recorlev (levoketoconazole)
- Relistor (methylnaltrexone)
- Remicade (infliximab)
- Renflexis (infliximab-abda)
- Repatha (evolocumab)
- Retacrit (epoetin alfa-epbx)
- Retisert (fluocinolone acetonide)
- Rezurock (belumosudil)
- Rinvoq (upadacitinib)
- Rituxan (rituximab)
- Ruconest (C1 esterase inhibitor (recombinant))
- Rukobia (fostemsavir)
- Ruzurgi (amifampridine)
S
- Sandostatin (octreotide), Sandostatin LAR (octreotide)
- Saphnelo (anifrolumab-fnia)
- Scenesse (Afamelanotide)
- Serostim (somatropin)
- Signifor, Signifor LAR (pasireotide)
- Siliq (brodalumab)
- Simponi (golimumab)
- Simponi Aria (golimumab)
- Skyrizi (risankizumab-rzaa)
- Skytrofa (lonapegsomatropin)
- Sogroya (somapacitan-beco)
- Soliris (eculizumab)
- Somavert (pegvisomant)
- Spinraza (nusinersen)
- Stelara (ustekinumab)
- Strensiq (asfotase alfa)
- Strensiq (asfotase alfa)
- Sublocade (buprenorphine extended-release) injection, for subcutaneous use
- Suboxone (buprenorphine and naloxone) sublingual film, for sublingual or buccal use
- Symdeko (tezacaftor/ivacaftor)
- Synagis (palivizumab)
T
- Takhzyro (lanadelumab-flyo)
- Taltz (ixekizumab)
- Tarpeyo (budesonide)
- Tavalisse (fostamatinib disodium hexahydrate)
- Tavneos (avacopan)
- Tecartus (brexucabtagene autoleucel)
- Tecfidera (dimethyl fumarate)
- Tegsedi (inotersen)
- Tepezza (teprotumumab-trbw)
- Tobi, Tobi Podhaler (tobramycin inhalation solution)
- Tremfya (guselkumab)
- Trikafta (elexacaftor/tezacaftor/ivacaftor and ivacaftor)
- Trogarzo (ibalizumab-uiyk)
- Tymlos (abaloparatide)
- Tysabri (natalizumab)
U
V
- Vabysmo (faricimab-svoa)
- Vigabatrin (generic for Sabril), Vigadrone
- Viltepso (viltolarsen)
- Vimizim (elosulfase alfa)
- VOXZOGO (vosoritide)
- Vumerity (diroximel fumarate)
- Vyepti (eptinezumab-jjmr)
- Vyndaqel (tafamidis meglumine) and Vyndamax (tafamidis)
- Vyondys 53 (golodirsen)
- Vyvgart (efgartigimod alfa-fcab)