MedicaidPrior AuthHigh impact
BT202572: Pharmacy updates approved by Drug Utilization Review Board May 2025
Indiana Medicaid (IHCP)·IN · Family Medicine, Internal Medicine, General Practice +3 more·Prior Authorization
Effective date
Jul 1, 2025
We identified it
Jun 18, 2026
Summary
Indiana Medicaid announces comprehensive updates to prior authorization requirements, preferred drug lists, and utilization edits for multiple medication categories including mental health drugs, diabetes medications, and specialty therapies. Key changes include new PA criteria for GLP-1 diabetes medications, updated quantity limits for mental health drugs like Spravato, and numerous preferred drug list status changes affecting coverage and step therapy requirements.
Action Required
By July 1, 2025: Billing team must update prior authorization protocols for multiple drug categories including Clonidine-Guanfacine, Opioid Overutilization, Proton Pump Inhibitors, GLP-1 RA/GIP RA combinations, and other specified medication classes. Update pharmacy billing systems to reflect new preferred drug list status changes for insulins, mental health medications, and specialty drugs. Review and implement new quantity limits for Spravato (esketamine) - 8 kits in month 1, then 4 kits/month thereafter for patients 18+. Download updated PA criteria from Optum Rx Indiana Medicaid website. Note: Managed care claims have different effective date of July 15, 2025.