12-15-35.5-1. Applicability
Sec. 1. This chapter applies to: (1) the Medicaid program under this article; and (2) the children’s health insurance program under IC 12-17.6. As added by P.L.6-2002, SEC.4. Amended by P.L.101-2005, SEC.5.
12-15-35.5-2. “Cross-Indicated Drug” Defined
Sec. 2. As used in this chapter, “cross-indicated drug” means a drug that is used for a purpose generally held to be reasonable, appropriate, and within the community standards of practice even though the use is not included in the federal Food and Drug Administration’s approved labeled indications for the drug. As added by P.L.6-2002, […]
12-15-35.5-2.5. “Unrestricted Access” Defined
Sec. 2.5. As used in this chapter, “unrestricted access” means the ability of a recipient to obtain a prescribed drug without being subject to limits or preferences imposed by the office or the board for the purpose of cost savings except as provided under section 7 of this chapter. As added by P.L.107-2002, SEC.23. Amended […]
12-15-35.5-2.6. “Waste”
Sec. 2.6. As used in this chapter, “waste” means inappropriate: (1) overprescribing; (2) underprescribing; (3) overutilization; (4) underutilization; (5) recipient noncompliance with the prescribed regimen; or (6) clinically unjustified utilization; of a prescription drug. As added by P.L.11-2010, SEC.2.
12-15-35.5-3. Prohibition on Prior Authorization of Mental Health Drugs; Exception
Sec. 3. (a) Except as provided in subsection (b), the office may establish prior authorization requirements for drugs covered under a program described in section 1 of this chapter. (b) With the exception of prior authorization for “brand medically necessary” of a brand name drug with a generic equivalent in accordance with IC 16-42-22-10, the […]
12-15-35.5-4. Prior Authorization Requirement Parameters
Sec. 4. Prior authorization requirements developed under this chapter must: (1) comply with all applicable state and federal laws, including the provisions of 405 IAC 5-3 and 42 U.S.C. 1396r-8(d)(5); and (2) provide that the prior authorization number assigned to an approved request be included on the prescription or drug order: (A) issued by the […]
12-15-35.5-5. Prior Authorization Procedures
Sec. 5. Before requiring prior authorization for a single source drug, the office shall seek the advice of the drug utilization review board, established by IC 12-15-35-19, at a public meeting of the board. As added by P.L.6-2002, SEC.4.
12-15-35.5-6. Publication of Prior Authorization Decision
Sec. 6. (a) The office shall publish the decision to require prior authorization for a single source drug in a provider bulletin. (b) IC 12-15-13-6 applies to a provider bulletin described in subsection (a). As added by P.L.6-2002, SEC.4.
12-15-35.5-7. Limitations on Drug Refills; Limitations on Restrictions on Certain Mental Health Drugs
Sec. 7. (a) Subject to subsections (b) and (c), the office may place limits on quantities dispensed or the frequency of refills for any covered drug as required by law or for the purpose of: (1) preventing fraud, abuse, or waste; (2) preventing overutilization, inappropriate utilization, or inappropriate prescription practices that are contrary to: (A) […]
12-15-35.5-7.5. Reimbursement for Methadone When Prescribed for Pain; Requirements
Sec. 7.5. (a) The office may reimburse under Medicaid for methadone if the drug was prescribed for the treatment of pain or pain management only as follows: (1) If the daily dosage is not more than sixty (60) milligrams. (2) If the daily dosage is more than sixty (60) milligrams, only if: (A) prior authorization […]
12-15-35.5-8. Restriction of Mental Health Drugs for Individuals Less Than 18 Years of Age
Sec. 8. In addition to the limits described in section 7 of this chapter, the office may restrict a mental health drug described in section 3 of this chapter that is prescribed for an individual who is less than eighteen (18) years of age if federal financial participation is not available for reimbursement for the […]
12-15-35.5-9. Reimbursement for Drugs Indicated Only for Addiction Treatment
Sec. 9. The office may not reimburse under Medicaid for Subutex, Suboxone, or a similar trade name or generic of the drug if the drug is only indicated for addiction treatment and was prescribed for the treatment of pain or pain management. As added by P.L.37-2016, SEC.2. Amended by P.L.10-2019, SEC.60.