MDwise Formulary Introduction Hoosier Healthwise (HHW)

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MDwise Formulary Introduction –Hoosier Healthwise (HHW)HHW members must use MDwise network pharmacies to access theirprescription drug benefit.How do I use the formulary?There are two ways to find your drug within the formulary:Medical ConditionDrugs in this formulary are grouped into categories depending on the type of medicalconditions that they are used to treat. For example, drugs used to treat a heart conditionare listed under the category “Cardiovascular Disease”. Then look under the categoryname for your drug.Alphabetical ListingThe Index provides an alphabetical list of all of the drugs included in this formulary.Both brand name drugs and generic drugs are listed in the Index. Look in the Index andfind your drug. Next to your drug, you will see the page number where you can findcoverage information. Turn to the page listed in the Index and find the name of yourdrug in the first column of the list. The formulary provides coverage information aboutdrugs covered by the plan. If you have trouble finding your drug in the list, turn to theIndex.All drugs are listed by their generic names and most common proprietary (branded)name. The Formulary may be accessed by using the Index, either by generic orproprietary name or by therapeutic drug category. In situations where an FDA-approvedgeneric equivalent is available, brand names are listed for reference purposes only, anddo not denote coverage for the brand name, unless specifically noted. All drugs are listedin each category in alphabetical order by generic name. Where an FDA-approved genericis available for the listed generic name, the generic name is bolded.

A generic drug has the same active-ingredient as the brand name drug. Generic drugsusually cost less than brand name drugs and are approved by the Food and DrugAdministration (FDA), which assures that the following conditions are met. The generic drug must contain the same active ingredients, be the same strength, andthe same dosage form as the brand name drug. The FDA has given an “A” rating compared to the brand name drug and thus thegeneric drug is determined to be therapeutically bioequivalent. When the above two criteria are met, a generic can be substituted with the fullexpectation that the substituted product will produce the same clinical effect andsafety profile as the prescribed product.Additional RequirementsSome covered drugs may have additional requirements or limits on coverage. Theserequirements and limits may include: Prior Authorization: MDwise requires you or your physician to get priorauthorization for certain drugs. This means that you will need to get approval fromthe pharmacy benefits manager (MedImpact) before you fill your prescription. If youdon’t get approval, the drug may not be covered. Drugs that are subject to a priorauthorization will have a “PA” symbol next to the drug. Physicians and Pharmaciescall (844) 336-2677 or FAX: (858) 790-7100.Quantity Limits: For certain drugs, the plan limits the amount of the drug that iscovered. Drugs that are subject to a quantity limit will have a “QL” symbol next tothe drug.Refill Limitations: Prescriptions may be refilled when 75% or more of the days’supply has been used.Step Therapy: In some cases, the plan requires you to first try certain drugs to treatyour medical condition before it will cover another drug for that condition. Forexample, if Drug A and Drug B both treat your medical condition, we may not coverDrug B unless you try Drug A first. If Drug A does not work for you, we will thencover Drug B. Drugs that are subject to Step Therapy will have a “ST” symbol nextto the drug.Age Limit: In some cases, drugs are only available to a member in a select agecategory. Drugs that are subject to an Age Limit will have an “AGE” symbol next tothe drug.Gender Limit: Some drugs are only available to members of a certain gender. Drugsthat are available to only a certain gender will have a “G” symbol next to the drug.You can find out if your drug has any additional requirements or limits by looking in theformulary starting on the next page.If you have any additional questions, please visit our website at mdwise.org or contact thecustomer service center at (844) 336-2677.

Table of ContentsAllergy. 3Antiemesis/Antivertigo.6Asthma And Copd. 6Autonomic Nervous System Disorders. 11Behavioral Health - Antidepressants. 12Behavioral Health - Other.14Cardiovascular Disease - Arrhythmia.23Cardiovascular Disease - Cardiac Stimulant.23Cardiovascular Disease - Hypertension. 23Cardiovascular Disease - Lipid Irregularity. 28Cardiovascular Disease - Miscellaneous Agents. 35Cardiovascular Disease - Vasodilation. 35Contraception/Oxytocics. 36Cough And Cold. 41Dermatology - Acne. 51Dermatology - Antiinfective. 53Dermatology - Antiinflammatory. 58Dermatology - Antipruritic Drugs. 60Dermatology - Miscellaneous. 60Dermatology - Pigmentation Disorders. 72Dermatology - Psoriasis/Eczema. 72Diabetes. 75Ear - General Disorders. 80Electrolyte Regulation. 81Endocrine Disorder - Fertility.83Endocrine Disorder - Other. 84Endocrine Disorder - Thyroid. 86Eye - General Disorders.87Eye - Glaucoma. 90Eye - Miscellaneous. 91Fluid Replacement. 92Gout And Related Diseases. 92Hematological Disorders. 92Hormonal Deficiency. 96Immunization. 98Immunosuppression/Modulation. 99Infectious Disease - Bacterial.100Infectious Disease - Fungal.102Infectious Disease - Miscellaneous. 103Infectious Disease - Parasitic. 104Infectious Disease - Viral. 104Inflammatory Disease. 108Local Anesthesia. 116Lower Gastrointestinal Disorders - Bowel Inflammat. 116Lower Gastrointestinal Disorders - Other. 118Medical Supplies. 123Miscellaneous Agents. 132Neoplastic Disease. 132Neurological Disease - Miscellaneous. 137Oral/Pharyngeal Disorders. 139Other Drugs.139Other Respiratory Disorders. 202Pain Management - Analgesics. 202Parkinsons Disease. 209Seizure Disorder. 210Skeletal Muscle Disorder. 212Smoking Cessation. 213Upper Gastrointestinal Disorders - Digestive. 2131

Upper Gastrointestinal Disorders - Spastic Disease. 215Upper Gastrointestinal Disorders - Ulcer Disease.215Urinary Tract - Functional Disorders. 218Vaginal Disorders. 220Vitamin And/Or Mineral Deficiency. 221Weight Reduction. 2762

DrugStatusNotesAllergy2Nd Gen Antihistamine & DecongestantCombinationsAll Day Allergy-DTier 1Allergy and Congestion ReliefTier 1Allergy Complete-DTier 1Allergy Relief D12Tier 1Allergy Relief D-24hrTier 1Allergy Relief,Nasal DecongestTier 1Allergy Relief-D (cetirizine)Tier 1Allergy-Congest Relief-D(fexo)Tier 1cetirizine-pseudoephedrineTier 1Clarinex-D 12 HOURTier 2fexofenadine-pseudoephedrineTier 1lorata-dine DTier 1Loratadine-DTier 1ST; QL (2 EA per 1 day)Allergenic Extracts, TherapeuticsOralairTier 2Palforzia (Level 1)Tier 2Palforzia (Level 2)Tier 2Palforzia (Level 3)Tier 2Palforzia (Level 4)Tier 2Palforzia (Level 5)Tier 2Palforzia (Level 6)Tier 2Palforzia (Level 7)Tier 2Palforzia (Level 8)Tier 2Palforzia (Level 9)Tier 2Palforzia (Level 10)Tier 2Palforzia (Level 11 Up-Dose)Tier 2Palforzia Initial DoseTier 2Palforzia Level 11 MaintenanceTier 2PAAntihistamines - 1St GenerationAhist (chlorcyclizine)Tier 2Ala-Hist IRTier 1Aller-ChlorTier 1Aller-G-TimeTier 1Allergy (chlorpheniramine)Tier 1Allergy (diphenhydramine) oral capsuleTier 1Allergy (diphenhydramine) oral tabletTier 1Allergy oral liquidTier 1Allergy Relief(chlorpheniramn) oral tabletTier 1Allergy Relief(diphenhydramin)Tier 1Allergy-TimeTier 13

DrugStatusBanophen oral capsuleTier 1Banophen oral tabletTier 1carbinoxamine maleate oral liquidTier 1carbinoxamine maleate oral tablet 4 mgTier 1Children's Allergy (diphenhyd) oral liquidTier 1Children's Allergy (diphenhyd) oral tablet,chewableTier 1Children's DiphenhydramineTier 1chlorpheniramine maleate oral tabletTier 1chlorpheniramine maleate oral tablet extended releaseTier 1clemastine oral tablet 2.68 mgTier 1Complete AllergyTier 1Complete Allergy MedicineTier 1cyproheptadineTier 1Dayhist AllergyTier 1DiphedrylTier 1Diphenhist oral capsuleTier 1diphenhydramine HCl oral capsuleTier 1diphenhydramine HCl oral dropsTier 1diphenhydramine HCl oral liquidTier 1diphenhydramine HCl oral tabletTier 1ED Chlorped JrTier 1Histex (triprolidine)Tier 2Histex PDTier 2Histex PDXTier 2hydroxyzine HCl oral solutionTier 1QL (100 ML per 1 day)hydroxyzine HCl oral tablet 10 mg, 25 mgTier 1QL (4 EA per 1 day)hydroxyzine HCl oral tablet 50 mgTier 1QL (8 EA per 1 day)hydroxyzine pamoateTier 1QL (4 EA per 1 day)Karbinal ERTier 2ST; QL (960 ML per 30 days)PediaClear-8Tier 2PediaventTier 2promethazine injectionTier 1promethazine oralTier 1Siladryl SATier 1triprolidine HClTier 1Valu-Dryl AllergyTier 1Antihistamines - 2Nd Generation24HR Allergy ReliefTier 1All Day Allergy (cetirizine)Tier 1Aller-easeTier 1Allergy Relief (cetirizine) oral capsuleTier 1Allergy Relief (cetirizine) oral tabletTier 1Allergy Relief (fexofenadine) oral tablet 180 mgTier 14Notes

DrugStatusNotesAllergy Relief (levocetirizin)Tier 1Allergy Relief (loratadine)Tier 1cetirizineTier 1Child Allergy Relf(cetirizine)Tier 1Children's Allergy Relief(lor)Tier 1Children's Allergy(cetirizine)Tier 1Children's CetirizineTier 1Children's LoratadineTier 1Child's All Day Allergy(cetir)Tier 1desloratadine oral tabletTier 1QL (1 EA per 1 day)desloratadine oral tablet,disintegratingTier 1ST; QL (1 EA per 1 day)fexofenadine oral tabletTier 1levocetirizine oral solutionTier 1levocetirizine oral tabletTier 1loratadine oral solutionTier 1loratadine oral tabletTier 1loratadine oral tablet,disintegratingTier 1ST; QL (10 ML per 1 day)Nasal Antihistamineazelastine nasalTier 1QL (60 ML per 30 days)olopatadine nasalTier 1QL (30.5 GM per 30 days)Tier 1ST; QL (23 GM per 30 days)Nasal Antihistamine & Anti-Inflam. Steroid Comb.azelastine-fluticasoneNasal Anti-Inflammatory Steroids24 Hour Nasal AllergyTier 1Allergy Relief (fluticasone)Tier 1QL (16 ML per 30 days)Beconase AQTier 2ST; QL (25 GM per 30 days)budesonide nasalTier 1flunisolideTier 1QL (25 ML per 30 days)fluticasone propionate nasalTier 1QL (16 GM per 30 days)mometasone nasalTier 1QL (17 GM per 30 days)Nasal AllergyTier 1OmnarisTier 2ST; QL (5 GM per 12 days)QNASL nasal HFA aerosol inhaler 40 mcg/actuationTier 2ST; QL (4.9 GM per 30 days)QNASL nasal HFA aerosol inhaler 80 mcg/actuationTier 2ST; QL (10.6 GM per 30 days)SinuvaTier 2triamcinolone acetonide nasalTier 1XhanceTier 2STZetonnaTier 2ST; QL (6.1 GM per 30 days)Nasal Mast Cell Stabilizers Agentscromolyn nasalTier 1Nasal Allergy Symptom ControlTier 15

DrugStatusNotesTier 1ST; QL (2 EA per 1 day)Akynzeo (netupitant)Tier 2QL (1 EA per 28 days)Anti-NauseaTier 1Antivert oral tablet 50 mgTier 2aprepitant oral capsule 125 mgTier 1QL (3 EA per 21 days)aprepitant oral capsule 40 mgTier 1QL (1 EA per 28 days)aprepitant oral capsule 80 mgTier 1QL (2 EA per 21 days)aprepitant oral capsule,dose packTier 1QL (3 EA per 21 days)BonjestaTier 2ST; QL (2 EA per 1 day)cola (syrup)Tier 1NOT COVERED IF TOTAL COST ISGREATER THAN 100ComproTier 1doxylamine-pyridoxine (vit B6)Tier 1DriminateTier 1Emend oral suspension for reconstitutionTier 2QL (3 EA per 21 days)granisetron HCl oralTier 1ST; QL (8 EA per 30 days)meclizine oral tablet 12.5 mg, 25 mgTier 1meclizine oral tablet,chewableTier 1Motion SicknessTier 1Motion Sickness (meclizine)Tier 1Motion Sickness ReliefTier 1Motion Sickness Relief(mecliz) oral tabletTier 1Motion-TimeTier 1Nausea ReliefTier 1ondansetronTier 1ondansetron HCl oral solutionTier 1ondansetron HCl oral tabletTier 1prochlorperazine EdisylateTier 1prochlorperazine maleateTier 1promethazine rectalTier 1QL (30 EA per 30 days)SancusoTier 2ST; QL (1 EA per 7 days)scopolamine baseTier 1Travel SicknessTier 1trimethobenzamide oralTier 1Antiemesis/AntivertigoAntiemetic, Cannibinoid-TypedronabinolAntiemetic/Antivertigo AgentsST; QL (4 EA per 1 day)QL (50 ML per 15 days)Asthma And Copd5-Lipoxygenase InhibitorszileutonTier 1ST; QL (2 EA per 1 day)ZyfloTier 2ST; QL (4 EA per 1 day)Tier 2QL (25.8 GM per 28 days)Anticholinergic, Orally Inhaled Short ActingAtrovent HFA6

DrugStatusipratropium bromide inhalationTier 1NotesAnticholinergics, Orally Inhaled Long ActingIncruse ElliptaTier 2QL (30 EA per 30 days)Lonhala Magnair RefillTier 2ST; QL (60 ML per 30 days)Lonhala Magnair StarterTier 2ST; QL (60 ML per 30 days)Spiriva RespimatTier 2QL (4 GM per 30 days)Spiriva with HandiHalerTier 2QL (1 EA per 1 day)Tudorza PressairTier 2ST; QL (1 EA per 30 days)YupelriTier 2QL (90 ML per 30 days)Beta-Adrenergic Agentsalbuterol sulfate oralTier 1metaproterenol oral syrupTier 1terbutaline oralTier 1Beta-Adrenergic Agents, Inhaled, Short Actingalbuterol sulfate inhalationTier 1levalbuterol HClTier 1levalbuterol tartrateTier 1Proair DigihalerTier 2ProAir RespiClickTier 2Beta-Adrenergic Agents, Inhaled, Ultra-LongActingStriverdi RespimatTier 2QL (4 GM per 30 days)arformoterolTier 1QL (60 ML per 15 days)formoterol fumarateTier 1QL (120 ML per 30 days)Serevent DiskusTier 2ST; QL (60 EA per 30 days)Anoro ElliptaTier 2QL (60 EA per 30 days)Bevespi AerosphereTier 2ST; QL (10.7 GM per 23 days)Combivent RespimatTier 2QL (8 GM per 30 days)Duaklir PressairTier 2STipratropium-albuterolTier 1Stiolto RespimatTier 2QL (4 GM per 30 days)Advair HFATier 2QL (12 GM per 30 days)AirDuo DigihalerTier 2ST; QL (1 EA per 30 days)Breo ElliptaTier 2QL (60 EA per 30 days)budesonide-formoterolTier 1ST; QL (30.6 GM per 30 days)Dulera inhalation HFA aerosol inhaler 100-5mcg/actuation, 50-5 mcg/actuationTier 2QL (39 GM per 30 days)Beta-Adrenergic Agents, Orally Inhaled,LongActingBeta-Adrenergic And AnticholinergicCombinationsBeta-Adrenergic And GlucocorticoidCombinations7

DrugStatusNotesDulera inhalation HFA aerosol inhaler 200-5mcg/actuationTier 2QL (13 GM per 30 days)fluticasone propion-salmeterol inhalation aerosolpowdr breath activatedTier 1QL (1 EA per 30 days)fluticasone propion-salmeterol inhalation blister withdeviceTier 1QL (60 EA per 30 days)Wixela InhubTier 1QL (60 EA per 30 days)Breztri AerosphereTier 2ST; QL (10.7 GM per 30 days)Trelegy ElliptaTier 2QL (60 EA per 30 aledGeneral Bronchodilator AgentsAsthmanefrin RefillTier 2Bronchial MistTier 1Bronchial Mist RefillTier 1S2 RacepinephrineTier 2Glucocorticoids, Orally InhaledAlvescoTier 2QL (2 GM per 19 days)ArmonAir DigihalerTier 2ST; QL (1 EA per 30 days)Arnuity ElliptaTier 2ST; QL (30 EA per 30 days)Asmanex HFA inhalation HFA aerosol inhaler 100mcg/actuation, 200 mcg/actuationTier 2ST; QL (1 GM per 23 days)Asmanex HFA inhalation HFA aerosol inhaler 50mcg/actuationTier 2ST; QL (13 GM per 30 days)Asmanex Twisthaler inhalation aerosol powdr breathactivated 110 mcg/ actuation (30), 220 mcg/ actuation(120), 220 mcg/ actuation (30), 220 mcg/ actuation(60)Tier 2ST; QL (1 EA per 23 days)budesonide inhalation suspension for nebulization0.25 mg/2 mL, 0.5 mg/2 mLTier 1QL (60 ML per 15 days)budesonide inhalation suspension for nebulization 1mg/2 mLTier 1QL (30 ML per 15 days)Flovent Diskus inhalation blister with device 100mcg/actuation, 50 mcg/actuationTier 2Prior prescription for Alvesco in past120 days if 12 years of age or older;QL (1 EA per 23 days)Flovent Diskus inhalation blister with device 250mcg/actuationTier 2Prior prescription for Alvesco in past120 days if 12 years of age or older;QL (2 EA per 23 days)Flovent HFA inhalation HFA aerosol inhaler 110mcg/actuationTier 2Prior prescription for Alvesco in past120 days if 12 years of age or older;QL (1 GM per 23 days)Flovent HFA inhalation HFA aerosol inhaler 220mcg/actuation, 44 mcg/actuationTier 2Prior prescription for Alvesco in past120 days if 12 years of age or older;QL (2 GM per 23 days)Pulmicort FlexhalerTier 2ST; QL (1 EA per 30 days)Qvar RediHaler inhalation HFA aerosol breathactivated 40 mcg/actuationTier 2ST8

DrugStatusNotesQvar RediHaler inhalation HFA aerosol breathactivated 80 mcg/actuationTier 2ST; QL (21.2 GM per 30 days)Dupixent PenTier 2PADupixent SyringeTier 2PAFasenraTier 2PAFasenra PenTier 2PAInterleukin-4(Il-4) Receptor Alpha Antagonist, MabInterleukin-5(Il-5) Receptor Alpha Antagonist, MabLeukotriene Receptor AntagonistsmontelukastTier 1zafirlukastTier 1Mast Cell Stabilizerscromolyn oralTier 1QL (20 ML per 1 day)Mast Cell Stabilizers, Orally Inhaledcromolyn inhalationTier 1Monoclonal Antibodies To Immunoglobulin E(Ige)XolairTier 2PA; QL (1 ML per 5 days)CinqairTier 2PANucalaTier 2PA; QL (1 EA per 28 days)Tier 2ST; QL (1 EA per 1 day)Monoclonal Antibody - Interleukin-5 AntagonistsPhosphodiesterase-4 (Pde4) InhibitorsDalirespRespiratory Aids,Devices,EquipmentAce Aerosol Cloud EnhancerTier 2Aerochamber MiniTier 2Aerochamber MVTier 2Aerochamber Plus Flow-VuTier 2Aerochamber Plus Flow-Vu,L MskTier 2Aerochamber Plus Flow-Vu,M MskTier 2Aerochamber Plus Flow-Vu,S MskTier 2Aerochamber Plus Z StatTier 2AeroChamber Plus Z Stat Lg MskTier 2AeroChamber Plus Z Stat Md MskTier 2AeroChamber Plus Z Stat Sm MskTier 2Aerochamber with FlowsignalTier 2AeroChamber Z-Stat Plus-Flw SgTier 2AeroTrach PlusTier 2Aerovent PlusTier 2BreatheRite MDI SpacerTier 2BreatheRite Spacer-Mask, Neo.Tier 2BreatheRite Spacer-Mask,AdultTier 2BreatheRite Spacer-Mask,ChildTier 2BreatheRite Spacer-Mask,InfantTier 29

DrugStatusBreatheRite Spacer-Mask,S.ChldTier 2BreatheRite Valved MDI ChamberTier 2BreatheRite Valved MDI SpacerTier 2Clever Choice Chamber-Lrg MaskTier 2Clever Choice Chamber-Med MaskTier 2Clever Choice Chamber-Sm MaskTier 2Compact Space ChamberTier 2Compact Space Chamber PlusTier 2Compact Space Chamber-Lrg MaskTier 2Compact Space Chamber-Med MaskTier 2Compact Space Chamber-Sm MaskTier 2EasiVent Holding ChamberTier 2EasiVent Mask LargeTier 2EasiVent Mask MediumTier 2EasiVent Mask SmallTier 2FlexichamberTier 2Flexichamber-Lg Child MaskTier 2Flexichamber-Sm Adult MaskTier 2Flexichamber-Sm Child MaskTier 2In-Check Dial Training DeviceTier 2InspiraChamberTier 2InspiraChamber with Mask-LargeTier 2InspiraChamber with Mask-MedTier 2InspiraChamber with Mask-SmallTier 2Lite Touch-Medium MaskTier 2LiteAire MDI ChamberTier 2LiteTouch-Large MaskTier 2LiteTouch-Small MaskTier 2MicrochamberTier 2MicrospacerTier 2MistAssistTier 2MistAssist KitTier 2MouthpieceTier 2One Way Valved MouthpieceTier 2Optichamber Adult Mask-LargeTier 2OptiChamber Diamond Lg MaskTier 2OptiChamber Diamond VHCTier 2OptiChamber Diamond-Med MskTier 2OptiChamber Diamond-Sml MaskTier 2Panda MaskTier 2Pediatric Medium MaskTier 2Pediatric Panda MaskTier 2Pediatric Small MaskTier 210Notes

DrugStatusPFLEX Inspiratory TrainerTier 2POCKET CHAMBERTier 2PrimeAireTier 2Pro Comfort Spacer-Adult MaskTier 2Pro Comfort Spacer-Child MaskTier 2Procare Spacer With Adult MaskTier 2Procare Spacer With Child MaskTier 2ProChamberTier 2RiteFlo AerochamberTier 2Sidestream Pediatric Face MaskTier 2Silicone Mask - InfantTier 2Silicone Mask - PediatricTier 2Space ChamberTier 2Space Chamber PlusTier 2Space Chamber with Large MaskTier 2Space Chamber with Medium MaskTier 2Space Chamber with Small MaskTier 2Threshold IMT TrainerTier 2Threshold PEP DeviceTier 2Vortex Adult MaskTier 2Vortex Holding ChamberTier 2Vortex VHC Frog Mask-ChildTier 2Vortex VHC Ladybug Mask-ToddlrTier 2WINDMILL TRAINERTier 2NotesXanthinesAlertness AidTier 1caffeineTier 1caffeine citrate oralTier 1Stay AwakeTier 1Stay Awake Maximum StrengthTier 1Theo-24Tier 2TheochronTier 1theophylline oral elixirTier 1theophylline oral solutionTier 1theophylline oral tablet extended release 12 hr 300mg, 450 mgTier 1theophylline oral tablet extended release 24 hrTier 1Autonomic Nervous System DisordersAlzheimer's Therapy, Nmda Receptor Antagonistsmemantine oral capsule,sprinkle,ER 24hrTier 1ST; QL (30 EA per 30 days)memantine oral solutionTier 1QL (10 ML per 1 day)memantine oral tabletTier 1QL (60 EA per 30 days)memantine oral tablets,dose packTier 1QL (2 EA per 1 day)11

DrugStatusNotesNamenda XR oral cap,sprinkle,ER 24hr dose packTier 2QL (28 EA per 28 days)Namzaric oral cap,sprinkle,ER 24hr dose packTier 2QL (28 EA per 28 days)Namzaric oral capsule,sprinkle,ER 24hrTier 2QL (1 EA per 1 day)donepezilTier 1QL (1 EA per 1 day)galantamine oral capsule,ext rel. pellets 24 hrTier 1QL (30 EA per 30 days)galantamine oral solutionTier 1QL (6 ML per 1 day)galantamine oral tabletTier 1QL (60 EA per 30 days)pyridostigmine bromide oral syrupTier 1pyridostigmine bromide oral tablet 60 mgTier 1pyridostigmine bromide oral tablet extended releaseTier 1rivastigmineTier 1QL (30 EA per 30 days)rivastigmine tartrateTier 1QL (2 EA per 1 day)Tier 1QL (1 EA per 1 day)Tier 2REQUIRES CONCURRENT USE OFAN ORAL ANTIDEPRESSANTMarplanTier 2QL (3 EA per 1 day)phenelzineTier 1QL (6 EA per 1 day)tranylcypromineTier 1QL (6 EA per 1 day)AplenzinTier 2Q

MDwise Formulary Introduction – Hoosier Healthwise (HHW) HHW members must use MDwise network pharmacies to access their prescription drug benefit. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition Drugs in this formulary are grouped into categories depending on the type of medical

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Hoosier Healthwise members must use MDwise network pharmacies to access their prescription drug benefit. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition Drugs in this formulary are grouped into categories depending on

Who is MDwise? A local, not-for-profit company serving Hoosier Healthwise (HHW) and Healthy Indiana Plan (HIP) members Exclusively serving Indiana families since 1994 oOver 355,000 members o3,000 primary care providers NCQA Accredited Health Plan 95% of MDwise member

Existing Hoosier Healthwise/HIP Market As of August 2015, there were just over 900,000 members enrolled in either Hoosier Healthwise or HIP. MDWise, a local non-profit MCO, is the largest in terms of market share

MDwise Total Health MDwise Community Health Network Claims Inquiries 1-800-356-1204 Medical Management & Prior Authorization 317-621-7575 / 800-344-8672 Fax: 317-983-7757 / 844-309-4009 Provider Representative 317-621-7593 Claim Dept. Address (includes behavioral claims) HIP Maternity Claims MDwise Community Health Network P.O. Box 331550

–Prior Authorization 6. Why Did My Claim “Deny”? . Hoosier Healthwise Hoosier Care Connect Healthy Indiana Plan Total Members Anthem 219,758 56,671 179,005 455,434 CareSource 51,004 N/A 36,145 87,149 MDwise 187,764 N/A 100,011 287,775 MH

In 2001, CIMCO teamed up with IU Health Plan (IUHP) and organized its affiliated providers under a new name, MDwise. In August 2007, MDwise was selected to begin negotiations to serve as an insurance provider for the Healthy Indiana Plan (HIP). Under the HIP program, the State of Indiana contracts with statewide, risk-bearing entities toFile Size: 1MBPage Count: 127myMDwise Provider Portal · Forms · Claims · Contact Information ·

will go into a POWER Account. POWER Account stands for Personal Wellness Responsibility Account. You will have 1,100 in your POWER Account. You will get a MDwise card in the mail. Use this MDwise card whenever you go to the doctor, the pharmacy or anytime that you get health care services. Except for your preventive care,File Size: 1MBPage Count: 31

American Board of Radiology American Board of Surgery American Board of Thoracic Surgery American Board of Urology ABMS and 24 Boards (Consolidated) Cash, Savings and Investments by Board Total Liabilities: Deferred Revenue, Deferre d Compensation and All Other by Board Retirement Plans: Net Assets, Inv Inc and Employer and Employee Contributions by Board ABMS and 24 Boards Board, Related .