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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

conditions that they are used to treat. For example, drugs used to treat a heart condition

are listed under the category “Cardiovascular Disease”. Then look under the category

name for your drug.

Alphabetical Listing

The 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 and

find your drug. Next to your drug, you will see the page number where you can find

coverage information. Turn to the page listed in the Index and find the name of your

drug in the first column of the list. The formulary provides coverage information about

drugs covered by the plan. If you have trouble finding your drug in the list, turn to the

Index.

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 or

proprietary name or by therapeutic 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 name, unless specifically 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 is bolded.

A generic drug has the same active-ingredient as the brand name drug. Generic drugs

usually cost less than brand name drugs and are approved by the Food and Drug

Administration (FDA), which assures that the following conditions are met.

• The generic drug must contain the same active ingredients, be the same strength, and

the same dosage form as the brand name drug.

• The FDA has given an “A” rating compared to the brand name drug and thus the

generic drug is determined to be therapeutically bioequivalent.

• When the above two criteria are met, a generic can be substituted with the full

expectation that the substituted product will produce the same clinical effect and

safety profile as the prescribed product.

Additional Requirements

Some covered drugs may have additional requirements or limits on coverage. These

requirements and limits may include:

• Prior Authorization: MDwise requires you or your physician to get prior

authorization for certain drugs. This means that you will need to get approval from

the pharmacy benefits manager (MedImpact) before you fill your prescription. If you

don’t get approval, the drug may not be covered. Drugs that are subject to a prior

authorization will have a “PA” symbol next to the drug. Physicians and Pharmacies

call (844) 336-2677 or FAX: (858) 790-7100.

• Quantity Limits: 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 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 treat

your medical condition before it will cover another drug for that condition. For

example, if Drug A and Drug B both treat your medical condition, we may not cover

Drug B unless you try Drug A first. If Drug A does not work for you, we will then

cover Drug B. Drugs that are subject 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 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 the

formulary starting on the next page.

If you have any additional questions, please visit our website at mdwise.org or contact the

customer service center at (844) 336-2677.

Table of Contents

Allergy....................................................................................................................................................................................... 3 Antiemesis/Antivertigo...............................................................................................................................................................6 Asthma And Copd..................................................................................................................................................................... 7 Autonomic Nervous System Disorders................................................................................................................................... 12 Behavioral Health - Antidepressants.......................................................................................................................................12 Behavioral Health - Other........................................................................................................................................................15 Cardiovascular Disease - Arrhythmia......................................................................................................................................21 Cardiovascular Disease - Cardiac Stimulant...........................................................................................................................21 Cardiovascular Disease - Hypertension..................................................................................................................................21 Cardiovascular Disease - Lipid Irregularity............................................................................................................................. 26 Cardiovascular Disease - Miscellaneous Agents.................................................................................................................... 28 Cardiovascular Disease - Vasodilation................................................................................................................................... 29 Contraception/Oxytocics......................................................................................................................................................... 29 Cough And Cold......................................................................................................................................................................34 Dermatology - Acne................................................................................................................................................................ 45 Dermatology - Antiinfective..................................................................................................................................................... 46 Dermatology - Antiinflammatory..............................................................................................................................................49 Dermatology - Antipruritic Drugs............................................................................................................................................. 51 Dermatology - Miscellaneous..................................................................................................................................................52 Dermatology - Pigmentation Disorders................................................................................................................................... 59 Dermatology - Psoriasis/Eczema............................................................................................................................................ 59 Diabetes.................................................................................................................................................................................. 60 Ear - General Disorders.......................................................................................................................................................... 69 Electrolyte Regulation............................................................................................................................................................. 69 Endocrine Disorder - Fertility ...................................................................................................................................................70 Endocrine Disorder - Other..................................................................................................................................................... 71 Endocrine Disorder - Thyroid.................................................................................................................................................. 73 Eye - General Disorders..........................................................................................................................................................74 Eye - Glaucoma..................