MDwise

Pharmacy Prior Authorization Quick Reference Guide

• Pharmacy Prior Authorization Quick Reference Guide for Hoosier Healthwise and HIP

Pharmacy Appeals Coversheet

• Pharmacy Appeals Coversheet for Hoosier Healthwise and HIP

Medication Request Forms for Hoosier Healthwise and HIP

• Brand Medically Necessary Medication
• Benzodiazepine and Opioid Concurrent Therapy PA Request Form
• Buprenorphine/naloxone (Bunavail, Suboxone Films, and Zubsolv)
• Diabetic Test Strips
• Lyrica CR (controlled-release)
• Lyrica IR (immediate-release)
• Opioid Analgesic Medical Necessity
• Opiood Analgesic Request to Exceed MME Daily Limit
• Synagis
• Medication Request Form (MRF) for all other drugs