MDwise

Mail Order Pharmacy

• Postal Prescription Services (PPS) Form for HIP

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
• Actemra
• Antipsychotics
• Benzodiazepine and Opioid Concurrent Therapy PA Request Form
• Buprenorphine/naloxone (Bunavail, Suboxone Films, and Zubsolv)
• BZD/Sedative Hypnotic Therapeutic Duplication Medical Necessity
• Cimzia
• CNS Stimulant Therapeutic Duplication Medical Necessity
• Corlanor
• Cosentyx
• Diabetic Test Strips and Meters
• Enbrel
• Entresto
• Humira
• Kineret
• MS Interferons (Avonex, Betaseron, Extavia, Plegridy, Rebif)
• Opioid Analgesic Medical Necessity
• Orencia SC
• Otezla
• Pulmozyme
• Simponi
• Stelara
• Synagis
• Xeljanz
• Medication Request Form (MRF) for all other drugs