MDwise Formulary Introduction – Hoosier Healthwise

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MDwise Formulary Introduction –Hoosier HealthwiseHoosier Healthwise 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 medical conditions thatthey are used to treat. For example, drugs used to treat a heart condition are listed under thecategory “Cardiovascular Disease”. Then look under the category name for your drug.Alphabetical ListingThe Index provides an alphabetical list of all the drugs included in this formulary. Both brand namedrugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to yourdrug, you will see the page number where you can find coverage information. Turn to the page listedin the Index and find the name of your drug in the first column of the list. The formulary providescoverage information about drugs covered by the plan. If you have trouble finding your drug in thelist, turn to the Index.All drugs are listed by their generic names and most common proprietary (branded) name. TheFormulary may be accessed by using the Index, either by generic or proprietary name or bytherapeutic drug category. In situations where an FDA-approved generic equivalent is available,brand names are listed for reference purposes only, and do not denote coverage for the brand, unlessspecifically noted. All drugs are listed in each category in alphabetical order by generic name.Where an FDA-approved generic is available for the listed generic name, the generic name isbolded.A generic drug as the same active-ingredient as the brand name drug. Generic drugs usually cost lessthan brand name drugs and are approved by the Food and Drug Administration (FDA), whichassures that the following conditions are met:

The generic drug must contain the same active ingredients, be the same strength, and the samedosage form as the brand name drug.The FDA has given an “A” rating compared to the brand name drug and thus the generic drug isdetermined to be therapeutically bioequivalent.When the above two criteria are met, a generic can be substituted with the full expectation thatthe substituted product will produce the same clinical effect and safety profile as the prescribedproduct.Additional RequirementsSome covered drugs may have additional requirements or limits on coverage. These requirementsand limits may include: Prior Authorization: MDwise requires you or your physician to get prior authorization forcertain drugs. This means that you will need to get approval from the pharmacy benefitsmanager (MedImpact) before you fill your prescriptions. If you don’t get approval, the drugmay not be covered. Drugs that are subject to a prior authorization will have a “PA” symbolnext to the drug. Physicians & Pharmacies call (844) 336-2677 or FAX: (858) 790-7100 Quantity Limit: For certain drugs, the plan limits the amount of the drug that is covered.Drugs that are subject to a quantity limit will have a “QL” symbol next to the drug. Refill Limitation: Prescription may be refilled when 75% or more of the day’s supply hasbeen used. Step Therapy: In some cases, the plan requires you to first try certain drugs to treat yourmedical condition before it will cover another drug for that condition. For example, if DrugA and Drug B both treat your medical condition, we may not cover Drug B unless you tryDrug A fist. If Drug A does not work for you, we will then cover Drug B. Drugs that aresubject to Step Therapy will have a “ST” symbol next to the drug. Age Limit: In some cases, drugs are only available to a member in a select age category.Drugs that are subject to an Age Limit will have an “AGE” symbol next to the drug. Gender Limit: Some drugs are only available to members of a certain gender. Drugs that areavailable to only a certain gender will have a “G” symbol next to the drug. You can find outif your drug as any additional requirements or limits by looking in the formulary starting onthe next page.If you have any additional questions, please visit our website mdwise.org or contact the customerservice center (844) 336-2677.

MDwise 2017 HCC HHW and HIP Basic FormularyLast Updated February 9 2017ContentsofTableTable of ContentsANALGESIC AND ANTIHISTAMINE COMBINATION .3ANALGESICS. 3ANESTHETICS.10ANTIALLERGY.12ANTIARTHRITICS. 12ANTIASTHMATICS. 14ANTIBIOTICS.16ANTICOAGULANTS. 23ANTIDOTES.24ANTIFUNGALS. 25ANTIHISTAMINE AND DECONGESTANT 31ANTIINFECTIVES.33ANTIINFECTIVES/MISCELLANEOUS .33ANTINEOPLASTICS. 33ANTIPARKINSON DRUGS. 38ANTIPLATELET DRUGS. 39ANTIVIRALS. 39AUTONOMIC DRUGS.42BIOLOGICALS.44BLOOD.46CARDIAC DRUGS . 48CARDIOVASCULAR.50CNS DRUGS. 54COLONY STIMULATING FACTORS .58CONTRACEPTIVES. 58COUGH/COLD PREPARATIONS . 62DIAGNOSTIC.69DIURETICS. 70EENT PREPS.71ELECT/CALORIC/H2O. 75GASTROINTESTINAL.82HERBALS. 91HORMONES.94IMMUNOSUPPRESANT . 98MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG. 98MUSCLE RELAXANTS .113PRE-NATAL VITAMINS.113PSYCHOTHERAPEUTIC DRUGS. 116SEDATIVE/HYPNOTICS . 124SKIN PREPS.125SMOKING DETERRENTS. 135THYROID PREPS.135UNCLASSIFIED DRUG PRODUCTS .135VITAMINS.1451

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MDwise 2017 HCC HHW and HIP Basic FormularyLast Updated February 9 2017Drug NameTierNotesANALGESIC AND ANTIHISTAMINECOMBINATIONACETA-GESIC1ACETAMINOPHEN PM1diphenhydramine-acetaminophen1HEADACHE PM1MAPAP PM1NON-ASPIRIN NIGHTIME1NON-ASPIRIN PM1PAIN RELIEF PM1PAIN RELIEF PM RAPID RELEASE1PAIN RELIEVER PM EX-STRENGTH1PAIN RELIEVER PM ORAL TABLET 25-500 MG1STAFLEX (BROMPHENIRA-ACETAMIN)2TYLENOL PM EXTRA STRENGTH1ANALGESICS8 HOUR PAIN RELIEVER1ABSTRAL2ACEPHEN1acetaminophen oral liquid 160 mg/5 ml1acetaminophen oral solution1acetaminophen oral tablet1acetaminophen oral tablet extended release1acetaminophen rectal1acetaminophen-caff-dihydrocod oral capsule1acetaminophen-codeine oral solution 120 mg-12 mg /5 ml(5 ml), 120-12 mg/5 ml, 240 mg-24 mg /10 ml (10 ml), 300mg-30 mg /12.5 ml1acetaminophen-codeine oral tablet1ADDED STRENGTH HEADACHE RELIEF1alfentanil1almotriptan malate1ST; QL (2 EA per 5 days)ALSUMA2QL (1 ML per 14 days)ARTHRITIS PAIN RELIEF (ACETAM)1ARTHRITIS PAIN RELIEVER1ASCOMP WITH CODEINE1PA; QL (4 EA per 1 day)QL (10 EA per 1 day)3

Drug NameTierNotesASPIR-813ASPIRIN LOW DOSE3aspirin oral tablet3aspirin oral tablet,chewable3aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg3aspirin eine-dihydrocodein1ASPIR-LOW3BACKACHE RELIEF EXTRA STRENGTH1BELBUCA2belladonna alkaloids-opium1BELLADONNA-OPIUM1BUFFERIN1BUPAP ORAL TABLET 50-300 MG2BUPRENEX2buprenorphine hcl injection1BUTALBITAL COMPOUND -acetaminophen1butalbital-acetaminophen-caff oral capsule1butalbital-acetaminophen-caff oral tablet 50-325-40 mg1butalbital-aspirin-caffeine oral capsule1butorphanol tartrate1BUTRANS2PA; QL (1 EA per 7 days)CAFERGOT2QL (10 EA per 7 days)CAMBIA2QL (3 EA per 10 days)CAPACET1CAPITAL WITH CODEINE2carisoprodol-asa-codeine1CHILDREN'S ACETAMINOPHEN ORAL SUSPENSION160 MG/5 ML1CHILDREN'S ASPIRIN3CHILDREN'S MAPAP1CHILDREN'S PAIN RELIEF ORAL SUSPENSION1CHILDREN'S PAIN RELIEVER ORAL SUSPENSION1CHILDREN'S PAIN RELIEVER ORALTABLET,DISINTEGRATING1CHILDREN'S PAIN-FEVER RELIEF ORALSUSPENSION1CHILDREN'S PAIN-FEVER RELIEF ORALTABLET,CHEWABLE1CHILDREN'S Q-PAP1CHILDREN'S SILAPAP1choline,magnesium salicylate14PA

Drug NameTierNotesclonidine (pf)1codeine sulfate oral tablet1codeine-butalbital-asa-caff1DEMEROL (PF)2diclofenac potassium1diflunisal1dihydroergotamine injection1QL (15 ML per 14 days)dihydroergotamine nasal1QL (8 ML per 28 days)E.C. PRIN3ECOTRIN1ED-APAP1EFFERVESCENT PAIN RELIEF1ELMIRON2EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.RELPELL 100-4 MG2QL (4 EA per 1 day)EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.RELPELL 20-0.8 MG, 30-1.2 MG, 50-2 MG, 60-2.4 MG, 803.2 MG2QL (2 EA per 1 day)ENDOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5325 MG, 7.5-325 MG1QL (12 EA per 1 day)EXCEDRIN MIGRAINE1fentanyl1PA; QL (1 EA per 3 days)fentanyl citrate1PA; QL (4 EA per 1 day)fentanyl citrate (pf) injection1fentanyl citrate (pf) intravenous pt controlled analgesiasyring 2,750 mcg/55 ml (50 mcg/ml)1fentanyl citrate (pf) intravenous syringe 100 mcg/2 ml (50mcg/ml)1fentanyl-bupivacaine-nacl (pf) injection solution 2 mcg/ml0.1 %, 2 mcg/ml- 0.125 %1fentanyl-ropivacaine-nacl (pf) epidural solution 2-0.1mcg/ml-%1fentanyl-ropivacaine-nacl (pf) injection solution 2-0.2mcg/ml-%1FENTORA2FEVER REDUCER1FEVERALL RECTAL SUPPOSITORY 120 MG, 325 MG,650 MG1FEVERALL RECTAL SUPPOSITORY 80 MG2FROVA2HEADACHE RELIEF (ASA-ACET-CAF)1HISTAFLEX2hydrocodone-acetaminophen oral solution 10-325 mg/15ml(15 ml), 5-163 mg/7.5ml(7.5ml), 7.5-325 mg/15 ml1QL (184 ML per 1 day)hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300mg, 7.5-300 mg1QL (13 EA per 1 day)hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325mg, 7.5-325 mg1QL (12 EA per 1 day)PA; QL (4 EA per 1 day)ST; QL (3 EA per 5 days)5

Drug NameTierNoteshydrocodone-acetaminophen oral tablet 10-500 mg, 5-500mg, 7.5-500 mg1QL (8 EA per 1 day)hydrocodone-acetaminophen oral tablet 10-650 mg, 10-660mg, 7.5-650 mg1QL (6 EA per 1 day)hydrocodone-acetaminophen oral tablet 2.5-325 mg1hydrocodone-acetaminophen oral tablet 7.5-750 mg1hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg,7.5-200 mg1hydromorphone (pf)1hydromorphone (pf)-0.9% nacl intravenous patientcontrol.analgesia soln1hydromorphone (pf)-0.9% nacl intravenous pt controlledanalgesia syring 10 mg/50 ml (0.2 mg/ml), 6 mg/30 ml (0.2mg/ml)1hydromorphone (pf)-0.9% nacl intravenous solution 0.2mg/ml1hydromorphone injection solution 2 mg/ml1hydromorphone injection syringe1hydromorphone oral liquid1hydromorphone oral tablet1hydromorphone oral tablet extended release 24 hr 12 mg, 16mg, 8 mg1PA; QL (1 EA per 1 day)hydromorphone oral tablet extended release 24 hr 32 mg1PA; QL (2 EA per 1 day)hydromorphone rectal1HYSINGLA ER2IBUPROFEN PM ORAL TABLET1ibuprofen-oxycodone1INFANT PAIN RELIEVER1INFANTS' PAIN AND FEVER1INFANTS' PAIN RELIEF1INFANT'S PAIN RELIEF ORAL DROPS,SUSPENSION80 MG/0.8 ML1INFANT'S PAIN RELIEVER1INFUMORPH pten-caf-acetaminophen oral tablet 65-20-325 mg1JR. STR NON-ASPIRIN PAIN1JUNIOR MAPAP1KADIAN ORAL CAPSULE,EXTEND.RELEASEPELLETS 200 MG2QL (4 EA per 1 day)KADIAN ORAL CAPSULE,EXTEND.RELEASEPELLETS 40 MG2QL (2 EA per 1 day)ketorolac injection cartridge1ketorolac injection solution 15 mg/ml, 30 mg/ml (1 ml)1ketorolac injection syringe 30 mg/ml1ketorolac intramuscular16QL (5 EA per 1 day)QL (1 EA per 1 day)

Drug NameTierNotesketorolac oral1LAZANDA NASAL SPRAY,NON-AEROSOL 100MCG/SPRAY, 400 MCG/SPRAY2levorphanol tartrate1LITE COAT ASPIRIN3LORCET (HYDROCODONE)1QL (12 EA per 1 day)LORCET HD1QL (12 EA per 1 day)LORCET PLUS ORAL TABLET 7.5-325 MG1QL (12 EA per 1 day)LORTAB ELIXIR ORAL SOLUTION 10-300 MG/15 ML2MAPAP (ACETAMINOPHEN) ORAL CAPSULE1MAPAP (ACETAMINOPHEN) ORALDROPS,SUSPENSION1MAPAP (ACETAMINOPHEN) ORAL LIQUID1MAPAP (ACETAMINOPHEN) ORAL SUSPENSION1MAPAP (ACETAMINOPHEN) ORAL TABLET1MAPAP (ACETAMINOPHEN) ORALTABLET,CHEWABLE1MAPAP ARTHRITIS PAIN1MAPAP EXTRA STRENGTH1MARGESIC1MARTEN-TAB1mefenamic acid1MENSTRUAL COMPLETE1MENSTRUAL RELIEF1meperidine (pf) injection solution 100 mg/ml, 25 mg/ml, 50mg/ml1meperidine injection cartridge1meperidine oral solution1QL (30 ML per 1 day)meperidine oral tablet1QL (6 EA per 1 day)methadone injection1PAMETHADONE INTENSOL1PAmethadone oral concentrate1PAmethadone oral solution1PAmethadone oral tablet1PAmethadone oral tablet,soluble1PAMETHADOSE ORAL TABLET,SOLUBLE1PAMIGERGOT2QL (5 EA per 7 days)MIGRAINE FORMULA1MIGRAINE RELIEF1morphine (pf) in 0.9 % nacl intravenous syringe 2 mg/2 ml(1 mg/ml)1morphine (pf) injection solution 0.5 mg/ml, 1 mg/ml1morphine (pf) intravenous patient control.analgesia soln1morphine concentrate oral solution1morphine in 0.9 % nacl intravenous solution 1 mg/ml1PA; QL (1 EA per 2 days)7

Drug NameTierNotesmorphine injection solution 15 mg/ml, 8 mg/ml1morphine injection syringe 10 mg/ml, 2 mg/ml, 4 mg/ml, 5mg/ml, 8 mg/ml1morphine intravenous1morphine oral capsule, er multiphase 24 hr 120 mg1QL (2 EA per 1 day)morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg,60 mg, 75 mg, 90 mg1QL (1 EA per 1 day)morphine oral capsule,extend.release pellets1QL (2 EA per 1 day)morphine oral solution1morphine oral tablet2morphine oral tablet extended release1morphine rectal1nalbuphine1naratriptan1NODOLOR1NON-ASPIRIN EXTRA STRENGTH ORAL TABLET1NON-ASPIRIN ORAL TABLET1NON-ASPIRIN PAIN RELIEF ORAL TABLET 500 MG1NUCYNTA2QL (6 EA per 1 day)NUCYNTA ER2QL (2 EA per 1 day)OPANA INJECTION2oxycodone oral capsule1oxycodone oral concentrate1oxycodone oral solution1oxycodone oral tablet1oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg,20 mg, 30 mg, 40 mg, 60 mg1QL (2 EA per 1 day)oxycodone oral tablet,oral only,ext.rel.12 hr 80 mg1QL (4 EA per 1 day)oxycodone-acetaminophen oral capsule1QL (8 EA per 1 day)oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325mg, 5-325 mg, 7.5-325 mg1QL (12 EA per 1 day)oxycodone-acetaminophen oral tablet 10-650 mg1QL (6 EA per 1 day)oxycodone-acetaminophen oral tablet 7.5-500 mg1QL (8 EA per 1 day)oxycodone-aspirin1OXYCONTIN ORAL TABLET,ORALONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG,40 MG, 60 MG2QL (2 EA per 1 day)OXYCONTIN ORAL TABLET,ORALONLY,EXT.REL.12 HR 80 MG2QL (4 EA per 1 day)oxymorphone oral tablet1oxymorphone oral tablet extended release 12 hr 10 mg, 15mg, 20 mg, 5 mg, 7.5 mg1QL (2 EA per 1 day)oxymorphone oral tablet extended release 12 hr 30 mg, 40mg1QL (4 EA per 1 day)PAIN AND FEVER1PAIN RELIEF (ACETAMIN-ASP-CAF)18QL (3 EA per 1 day)QL (3 EA per 5 days)

Drug NameTierNotesPAIN RELIEF EXTRA STRENGTH1PAIN RELIEF ORAL TABLET1PAIN RELIEF ORAL TABLET EXTENDED RELEASE1PAIN RELIEF REGULAR STRENGTH1PAIN RELIEVER1PAIN RELIEVER EXTRA STRENGTH1PAIN RELIEVER PLUS1pentazocine-naloxone1PHARBETOL1PRE-MENSTRUAL RELIEF1PRIALT2PRIMLEV2Q-PAP1Q-PAP EXTRA STRENGTH1RELPAX2REPREXAIN1RIMSO-502rizatriptan1QL (3 EA per 5 days)ROXICET ORAL SOLUTION1QL (61 ML per 1 day)ROXICET ORAL TABLET 5-325 MG1QL (12 EA per 1 day)ROXICET ORAL TABLET 5-500 MG1QL (8 EA per 1 day)SUBSYS2PA; QL (4 EA per 1 day)sufentanil citrate1sumatriptan1QL (6 EA per 15 days)sumatriptan succinate oral1QL (3 EA per 5 days)sumatriptan succinate subcutaneous cartridge1QL (1 ML per 14 days)sumatriptan succinate subcutaneous pen injector1QL (1 ML per 14 days)sumatriptan succinate subcutaneous solution1QL (1 ML per 14 days)sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml1QL (1 ML per 14 days)SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLEFREE INJECTOR 4 MG/0.5 ML2ST; QL (4 ML per 28 days)SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLEFREE INJECTOR 6 MG/0.5 ML2ST; QL (1 ML per 14 days)TACTINAL1TACTINAL EXTRA STRENGTH1TALWIN2TENSION HEADACHE1tramadol oral capsule,er biphase 24 hr 17-831ST; QL (1 EA per 1 day)tramadol oral capsule,er biphase 24 hr 25-75 100 mg, 200mg1ST; QL (1 EA per 1 day)tramadol oral tablet1tramadol oral tablet extended release 24 hr1tramadol oral tablet, er multiphase 24 hr1tramadol-acetaminophen1TREXIMET ORAL TABLET 85-500 MG2QL (13 EA per 1 day)ST; QL (2 EA per 5 days)ST; QL (1 EA per 3 days)9

Drug NameTierNotesTRI-BUFFERED ASPIRIN1ULTIVA2VANATOL LQ2VICODIN1QL (13 EA per 1 day)VICODIN ES1QL (13 EA per 1 day)VICODIN HP1QL (13 EA per 1 day)XARTEMIS XR2QL (12 EA per 1 day)XYLON 101ZAMICET2ZEBUTAL ORAL CAPSULE 50-325-40 MG1ZECUITY2ST; QL (4 EA per 28 days)ZEMBRACE SYMTOUCH2STZIPSOR2ST; QL (4 EA per 1 day)ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER12HR2QL (2 EA per 1 day)zolmitriptan1ST; QL (2 EA per 5 days)ZOMIG NASAL SPRAY,NON-AEROSOL 2.5 MG2ST; QL (12 EA per 30 days)ZOMIG NASAL SPRAY,NON-AEROSOL 5 MG2ST; QL (6 EA per 15 days)ANESTHETICSAMIDATE2BREVITAL INJECTION RECON SOLN 2.5 GRAM, 500MG2BUFFERED LIDOCAINE INJECTION SYRINGE 1 % (1ML)2bupivacaine1bupivacaine (pf) injection solution1bupivacaine in nacl(pf) epidural solution 0.125 % acaine-epinephrine1bupivacaine-epinephrine (pf)1bupivacaine-epinephrine bitart1BURN RELIEF1CEPACOL SORE THROAT (BENZ-MEN) MUCOUSMEMBRANE LOZENGE 15-2.6 MG2cocaine1dibucaine1etomidate1GLYDO1ketamine in 0.9 % sod chloride intravenous syringe 50 mg/5ml (10 mg/ml)1ketamine injection1LANACANE FIRST AID2lidocaine1lidocaine (pf) in d7.5w110QL (184 ML per 1 day)

Drug NameTierlidocaine (pf) injection solution1lidocaine hcl injection solution1lidocaine hcl laryngotracheal1lidocaine hcl mucous membrane1lidocaine hcl topical cream 3 %1LIDOCAINE VISCOUS1lidocaine-epinephrine (pf)1lidocaine-epinephrine bit injection cartridge 2 %-1:100,0002lidocaine-epinephrine bit injection cartridge 2 %-1:50,0001lidocaine-epinephrine injection solution 0.5 %-1:200,000, 1%-1:100,000, 2 %-1:100,0001lidocaine-prilocaine1mepivacaine (pf)1midazolam (pf) injection1midazolam in 0.9 % nacl intravenous solution 1 mg/ml1midazolam in 0.9 % nacl intravenous syringe 2 mg/2 ml (1mg/ml)1midazolam injection1NAROPIN (PF)2NESACAINE INJECTION SOLUTION 10 MG/ML (1 %)2NESACAINE-MPF INJECTION SOLUTION 20 MG/ML(2 %)1NESACAINE-MPF INJECTION SOLUTION 30 MG/ML(3 %)2ORAL PAIN RELIEF MUCOUS MEMBRANE GEL1ORASEP2PHENASEPTIC1phenazopyridine oral tablet 100 mg, 200 mg1POLOCAINE INJECTION SOLUTION1POLOCAINE-MPF1propofol intravenous emulsion1ropivacaine (pf) injection solution1SARNA SENSITIVE1SENSORCAINE/EPINEPHRINE1SENSORCAINE-MPF INJECTION SOLUTION 0.75 %(7.5 MG/ML)1SENSORCAINE-MPF SPINAL1SENSORCAINE-MPF/EPINEPHRINE INJECTIONSOLUTION 0.25 %-1:200,000, 0.75 %-1:200,0001sevoflurane1SORE THROAT1SORE THROAT (BENZOCAINE-MENTH) MUCOUSMEMBRANE LOZENGE 15-3.6 MG1SORE THROAT (PHENOL)1SUPRANE2SYNERA2Notes11

Drug NameTiertetracaine hcl (pf) injection1URINARY PAIN RELIEF1XYLOCAINE INJECTION SOLUTION 5 MG/ML (0.5 %)2XYLOCAINE-MPF INJECTION SOLUTION 10 MG/ML(1 %), 20 MG/ML (2 %), 5 MG/ML (0.5 %)1XYLOCAINE-MPF INJECTION SOLUTION 15 MG/ML(1.5 %)2XYLOCAINE-MPF/EPINEPHRINE INJECTIONSOLUTION 1 %-1:200,0002ZINGO2NotesANTIALLERGYcromolyn oral1ANTIARTHRITICSALL DAY PAIN RELIEF1ALL DAY RELIEF1allopurinol1ALOPRIM2CALDOLOR INTRAVENOUS RECON SOLN 800 MG/8ML (100 MG/ML)2celecoxib1CHILD IBUPROFEN1CHILDREN'S IBUPROFEN1colchicine oral capsule1colchicine oral tablet1CUPRIMINE2DEPEN TITRATABS2diclofenac sodium 2ENBREL2PAENBREL SURECLICK2PAetodolac1fenoprofen oral capsule 400 mg2fenoprofen oral tablet1flurbiprofen1glucosam su dip-chondroit-c-mn1glucosamine sulfate oral capsule 500 mg1HUMIRA2PAHUMIRA PEDIATRIC CROHN'S START2PAHUMIRA PEN2PAHUMIRA PEN CROHN'S-UC-HS START2PAHUMIRA PEN PSORIASIS-UVEITIS2PAIBU-DROPS112QL (4 EA per 1 day)ST; QL (3 EA per 1 day)

Drug NameTierNotesIBUPROFEN IB1IBUPROFEN JR STRENGTH1ibuprofen oral capsule1ibuprofen oral suspension1ibuprofen oral tablet 200 mg, 400 mg, 600 mg, 800 mg1INDOCIN2indomethacin oral1INFANTS IBU-DROPS1INFANT'S IBUPROFEN1ketoprofen oral capsule1ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg1KINERET2leflunomide1meclofenamate oral1meloxicam1nabumetone1NAPRELAN CR ORAL TABLET, ER MULTIPHASE 24HR 750 MG2naproxen1naproxen sodium oral capsule1naproxen sodium oral tablet1naproxen sodium oral tablet, er multiphase 24 hr1ORENCIA2PAORENCIA (WITH MALTOSE)2PAOTEZLA2PAOTEZLA STARTER2PAOTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR10 MG/0.4 ML, 15 MG/0.4 ML, 20 MG/0.4 ML, 25MG/0.4 ML, 7.5 MG/0.4 ML2ST; QL (1.6 ML per 28 chicine1PROVIL1RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10MG/0.2 ML2ST; QL (0.8 ML per 28 days)RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR12.5 MG/0.25 ML2ST; QL (1 ML per 28 days)RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 15MG/0.3 ML2ST; QL (1.2 ML per 28 days)RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR17.5 MG/0.35 ML2ST; QL (1.4 ML per 28 days)RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 20MG/0.4 ML2ST; QL (1.6 ML per 28 days)RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR22.5 MG/0.45 ML2ST; QL (1.8 ML per 28 days)PA13

Drug NameTierNotesRASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 25MG/0.5 ML2ST; QL (2 ML per 28 days)RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR27.5 MG/0.55 ML2ST; QL (2.2 ML per 28 days)RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 30MG/0.6 ML2ST; QL (2.4 ML per 28 days)RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 7.5MG/0.15 ML2ST; QL (0.6 ML per 28 I ARIA2PAsulindac oral1TIVORBEX2tolmetin1ULORIC2ST; QL (30 EA per 30 days)VIMOVO2STVIVLODEX2XELJANZ2PAXELJANZ XR2PAZORVOLEX2ST; QL (3 EA per 1 day)ZURAMPIC2ST; QL (1 EA per 1 day)PA; ST; QL (3 EA per 1 day)ANTIASTHMATICSacetylcysteine1ADVAIR DISKUS2ADVAIR HFA2QL (12 GM per 30 days)AEROSPAN2QL (17.8 GM per 30 days)albuterol sulfate inhalation solution for nebulization1albuterol sulfate oral1ALVESCO2aminophylline intravenous1ANORO ELLIPTA2QL (60 EA per 30 days)ARCAPTA NEOHALER2ST; QL (1 EA per 1 day)ARNUITY ELLIPTA2ST; QL (30 EA per 30 days)ASMANEX HFA2ST; QL (13 GM per 30 days)ASMANEX TWISTHALER INHALATION AEROSOLPOWDR BREATH ACTIVATED 110 MCG (30 DOSES),220 MCG (120 DOSES), 220 MCG (14 DOSES), 220MCG (30 DOSES), 220 MCG (60 DOSES)2ST; QL (1 EA per 30 days)ASTHMANEFRIN REFILL2ATROVENT HFA2QL (25.8 GM per 28 days)BREO ELLIPTA2QL (60 EA per 30 days)BROVANA2QL (60 ML per 15 days)budesonide inhalation suspension for nebulization 0.25mg/2 ml, 0.5 mg/2 ml1QL (60 ML per 15 days)14ST; QL (12.2 GM per 25 days)

Drug NameTierNotesbudesonide inhalation suspension for nebulization 1 mg/2ml1COMBIVENT RESPIMAT2cromolyn inhalation1cromolyn nasal1DALIRESP2ST; QL (1 EA per 1 day)DULERA2QL (13 GM per 30 days)ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML1FLOVENT DISKUS INHALATION BLISTER WITHDEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION2ST; QL (2 EA per 1 day)FLOVENT DISKUS INHALATION BLISTER WITHDEVICE 250 MCG/ACTUATION2ST; QL (4 EA per 1 day)FLOVENT HFA INHALATION HFA AEROSOLINHALER 110 MCG/ACTUATION2ST; QL (12 GM per 30 days)FLOVENT HFA INHALATION HFA AEROSOLINHALER 220 MCG/ACTUATION2ST; QL (24 GM per 30 days)FLOVENT HFA INHALATION HFA AEROSOLINHALER 44 MCG/ACTUATION2ST; QL (21.2 GM per 30 days)FORADIL AEROLIZER2ST; QL (60 EA per 30 d

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

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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

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

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