Indiana Medicaid (IHCP) GLP-1 Coverage (2026): Pattern #16 — Regulatory-Exclusion Adult Non-Coverage With EPSDT-Only Pediatric Carve-In and Zepbound-Preferred-for-T2D-Only Anomaly (405 IAC 5-24-3(b)(1) + December 1, 2025 OptumRx SUPDL V1.0 + HB 1202 Fiscal Note Adult-Exclusion Verbatim + IHCP Bulletin BT2023148 EPSDT Carve-In)

TL;DR

Indiana Medicaid — officially the Indiana Health Coverage Programs (IHCP), administered by the FSSA Office of Medicaid Policy and Planning through OptumRx as the statewide pharmacy benefit manager — does not cover GLP-1 receptor agonists for adult chronic weight management. The exclusion is categorical, anchored in state administrative code at 405 IAC 5-24-3(b)(1) (“Anorectics or any agent used to promote weight loss”), and reproduced verbatim on page 1 of the December 1, 2025 OptumRx Indiana Medicaid Statewide Uniform Preferred Drug List (SUPDL V1.0).

Indiana is the first state in this 16-state series whose preferred drug list lists Zepbound (tirzepatide) as a PREFERRED agent in the GIP/GLP-1 RA class — while simultaneously excluding all weight-management indications from coverage at the regulation level. Zepbound’s preferred status is a procurement and rebate decision, established by the DUR Board on May 16, 2025 (effective July 1, 2025). The published PA criteria gate every covered Zepbound indication on type-2 diabetes mellitus — not on chronic weight management. An adult Hoosier with an obesity-only diagnosis cannot obtain Zepbound through Indiana Medicaid despite its preferred SUPDL status.

An EPSDT pediatric carve-in covers members under age 21 per IHCP Bulletin BT2023148 (October 31, 2023), which authorizes prior-authorization review for Wegovy (semaglutide) and Saxenda (liraglutide) for morbid obesity with comorbid conditions. Adults remain excluded under 405 IAC 5-24-3(b)(1). The HB 1202 Fiscal Note (LSA, Jason Barrett, January 3, 2025) states verbatim: “Indiana Medicaid does not currently cover weight management medication to members age 21 or older.” This is the most operationally direct agency-attested adult-exclusion statement in the 16-state series.

Pattern #16 — Per-state taxonomy positioning

Indiana is classified as Pattern #16: Regulatory-exclusion adult non-coverage with EPSDT-only pediatric carve-in and Zepbound-preferred-for-T2D-only anomaly. Its closest twin in the series is Illinois (Pattern #5), which anchors its exclusion in 89 IAC § 140.441(b) (“anorectic drugs or combinations”). Indiana uses the parallel language at 405 IAC 5-24-3(b)(1) (“Anorectics or any agent used to promote weight loss”) — both are state administrative code rules in the same regulatory register invoking the federal optional-exclusion authority at 42 U.S.C. § 1396r-8(d)(2)(A).

The structural difference from Illinois: Indiana’s December 1, 2025 SUPDL explicitly lists Zepbound as PREFERRED in the GIP/GLP-1 RA subclass, while the Illinois HFS PDL omits Zepbound entirely. This makes Indiana the clearest illustration in the series of the PDL preferred ≠ clinical coverage distinction — a counterintuitive surface that patients, prescribers, and journalists who don’t distinguish between formulary classification and indication-specific benefit authorization will misread as meaning Zepbound is “covered.”

Tennessee and Indiana are mirror-image case studies: both states faced the same fiscal question in their respective 2025 legislative sessions; Tennessee enacted a coverage expansion by formal rulemaking (effective August 1, 2025), while Indiana’s companion bill HB 1202 (Shackleford) died in committee without a floor vote.

405 IAC 5-24-3(b)(1) — the state regulatory anchor

The categorical adult-exclusion authority in Indiana is a state administrative code rule — not merely a PDL omission, an agency-manual item, or a contractor-level exclusion. 405 IAC 5-24-3 (“Coverage of legend drugs”) sits in Title 405 (Office of the Secretary of Family and Social Services), Article 5 (Medicaid Pharmacy Services). It can only be amended by the FSSA Secretary through the Indiana Administrative Code notice-and-comment rulemaking process — a higher threshold than a PDL update or a policy bulletin.

Verbatim 405 IAC 5-24-3(a) — the qualifying-drug clause:

“(a) The Medicaid program covers a drug that is: (1) approved by the United States Food and Drug Administration; (2) not designated by the Centers for Medicare and Medicaid Services (CMS) as less than effective, or identical, related, or similar to a less than effective drug; (3) subject to the terms of a rebate agreement between the drug’s manufacturer and CMS; and (4) not specifically excluded from coverage by Medicaid.”

Verbatim 405 IAC 5-24-3(b) — the exclusion clause:

“(b) The following drugs are specifically excluded from coverage: (1) Anorectics or any agent used to promote weight loss. (2) Topical minoxidil preparations. (3) Fertility enhancement drugs. (4) Drugs when prescribed solely or primarily for cosmetic purposes.”

Subsection (b)(1) is the operative bar. The phrase “or any agent used to promote weight loss” is broader than the older federal anorectic terminology — Indiana wrote the rule with categorical-effect language that captures GLP-1 receptor agonists used for weight management even though they are not pharmacologically anorectic in the amphetamine-class sense. This language mirrors the federal optional-exclusion authority at 42 U.S.C. § 1396r-8(d)(2)(A) — which permits, but does not require, states to exclude “Agents when used for anorexia, weight loss, or weight gain.” Indiana exercised that permissive federal authority by enacting 405 IAC 5-24-3(b)(1). The one-tier difference from Arizona (whose primary anchor is an agency billing manual item, not an administrative code rule) and from Georgia (whose exclusion is operational by PDL omission) makes Indiana’s anchor among the most durable primary-source citations in the series.

The December 1, 2025 OptumRx SUPDL reproduces this exclusion verbatim on its first page, making the SUPDL itself an operational confirmation of the regulatory bar — not an independent source of the exclusion.

December 1, 2025 SUPDL — Zepbound preferred, Wegovy non-preferred

The OptumRx Indiana Medicaid Statewide Uniform Preferred Drug List (SUPDL V1.0, effective December 1, 2025) is the operational pharmacy formulary for all IHCP programs — FFS and all four MCOs — administered through OptumRx (BIN not published in the SUPDL; FFS PA help desk 855-577-6317, fax 855-577-6384). The SUPDL’s first page reproduces the 405 IAC 5-24-3 exclusion:

“Indiana Health Coverage Programs (IHCP) Drug Coverage. In accordance with 405 IAC 5-24, the IHCP covers all FDA-approved legend drugs with the exception of the following: • Drugs designated by Centers for Medicare and Medicaid Services (CMS, formerly HCFA) as ‘less than effective’ (DESI), or identical, related, or similar to a DESI drug • Anorectics or any agent used to promote weight loss • Topical minoxidil preparations • Fertility enhancement drugs • Drugs used primarily or solely for cosmetic purposes”

Page 31 of the same SUPDL then lists the GLP-1 Receptor Agonists and Combinations class. The complete verbatim listing:

“DRUG CLASS: GLP-1 Receptor Agonists and Combinations PREFERRED: GLP-1 RA — PA criteria must be met for the following: • liraglutide (authorized generic and generic Victoza) • Ozempic • Trulicity • Victoza GIP/GLP-1 RA — PA criteria must be met for the following: • Zepbound Combination Agents — PA criteria must be met for the following: • Soliqua NON-PREFERRED: GLP-1 RA — PA criteria must be met for the following: • exenatide • Rybelsus • Wegovy GIP/GLP-1 RA — PA criteria must be met for the following: • Mounjaro Combination Agents — PA criteria must be met for the following: • Xultophy”

Zepbound’s preferred status was first established by the Indiana DUR Board at its May 16, 2025 meeting. IHCP Bulletin BT202572 (May 29, 2025) states verbatim:

“GLP-1 Receptor Agonists and Combinations: exenatide (generic Byetta) — Nonpreferred (previously preferred). Wegovy (semaglutide) — Nonpreferred (previously neutral). Zepbound (tirzepatide) — Preferred (previously neutral).”

Effective for FFS dates of service on or after July 1, 2025, and managed care dates of service on or after July 15, 2025. Saxenda, Qsymia, Contrave, phentermine, orlistat, and Xenical do not appear anywhere in the SUPDL body — consistent with the 405 IAC 5-24-3(b)(1) categorical exclusion.

The “PDL preferred ≠ clinical coverage” anomaly

Indiana is the first and only state in this 16-state series whose statewide PDL lists Zepbound as PREFERRED while simultaneously excluding all adult weight-management indications from coverage at the regulation level. Understanding why requires distinguishing two separate administrative decisions that happen to share the same document:

1. PDL Preferred status is a procurement and supplemental-rebate classification. When the Indiana DUR Board moved Zepbound from “neutral” to “Preferred” in May 2025, it was making a financial decision: Indiana Medicaid negotiates supplemental rebates with Eli Lilly based on Zepbound’s preferred placement, reducing the net unit cost to the state for every prescription dispensed under a covered indication. The DUR Board had no reason to simultaneously expand the covered-indication set — and it did not.

2. Clinical coverage is a benefit-policy decision governed by the PA criteria document. The OptumRx-published PA criteria for Zepbound (effective April 15, 2025, per IHCP Bulletin BT202538) gate access on type-2 diabetes mellitus for adult members — not on chronic weight management. IHCP Bulletin BT202538 states verbatim:

“Changes to the PA criteria for Cystic Fibrosis Agents, Niemann-Pick Disease Agents, Non-SUPDL Agents PA and Step Therapy, Transthyretin Stabilizer Agents, and Zepbound will be effective for PA requests submitted on or after April 15, 2025. PA criteria for Cystic Fibrosis Agents, Non-SUPDL Agents PA and Step Therapy, and Transthyretin Stabilizer Agents apply to the fee-for-service (FFS) benefit only.”

An adult Hoosier with an obesity-only diagnosis submitting a Zepbound PA request through Indiana Medicaid will receive a denial — not because Zepbound is absent from the SUPDL, but because the weight-management indication is excluded from the underlying benefit at 405 IAC 5-24-3(b)(1). The SUPDL preferred classification does not override that regulatory bar.

Compare this to Tennessee: TennCare’s May 1, 2026 PDL also lists Zepbound as Preferred — but Tennessee enacted Sequence 10-34-25 (effective January 26, 2026), which affirmatively carved the weight-management indication back in by amending four rule provisions to add “except for weight loss drugs when prescribed for treatment of obesity.” Indiana has no analogous carve-back-in. The same preferred-PDL surface produces opposite clinical access outcomes depending on whether the underlying state rule has been amended.

This anomaly is the cleanest illustration in the 50-state series that PDL preferred status is a procurement/rebate decision, not a clinical-coverage authorization. Patients, prescribers, and journalists who read the SUPDL GLP-1 class listing without reading the PA criteria document will mistakenly conclude that Zepbound is covered for any FDA-approved indication in Indiana Medicaid.

The CareSource Healthy Indiana Plan (HIP) Plus / HIP State Plan Plus / Hoosier Healthwise PDL (effective April 1, 2026, document IN-MED-M-3083119-V.3) mirrors this exactly: Zepbound appears as Tier 2 / PA under “INCRETINMIMETICS,” while the “ANTI-OBESITY DRUGS” section header appears in the table of contents but the body section contains no enumerated drug entries (confirmed by exhaustive text extraction). Wegovy and Saxenda are absent from the CareSource April 1, 2026 PDL body entirely.

HB 1202 Fiscal Note — the agency-attested adult-exclusion record

The most operationally direct statement of Indiana’s adult-exclusion policy in any primary source in this 16-state series appears not in a regulatory citation but in a legislative fiscal note. The HB 1202 Fiscal Impact Statement, prepared by Jason Barrett of the Legislative Services Agency (LSA) Office of Fiscal and Management Analysis on January 3, 2025, states verbatim:

“Currently, FDA-approved GLP-1 drugs are eligible for Medicaid reimbursement in Indiana to members under the age of 21 through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. Indiana Medicaid does not currently cover weight management medication to members age 21 or older.”

This single sentence is the cleanest adult-exclusion documentation found in any primary-source document across the entire 16-state series. Most other states’ exclusions must be inferred from PDL omission, regulatory citation, or external KFF tracker. Indiana’s exclusion is stated in the state’s own legislative fiscal services agency’s analysis of a bill that would have reversed it.

The same Fiscal Note confirms Indiana’s T2D GLP-1 spending context:

“Indiana’s state Medicaid program currently covers FDA-approved GLP-1 drugs to treat diabetes. In FY 2024, the average cost per claim for such drugs totaled $1,019 with an average cost per client of $3,659. It is expected that costs will be similar if the drug is prescribed to individuals for weight management.”

The Fiscal Note also confirms that bariatric surgery is covered under traditional Medicaid (but not for HIP Basic or HIP Plus members), and that Michele Holtkamp, FSSA spokesperson, projected weight-management GLP-1 coverage at 5%–20% enrollment penetration would cost $11 million to $314 million annually (reported in December 2024 Indiana Lawyer and Inside Indiana Business coverage of FSSA fiscal projections).

YMYL note: The Fiscal Note’s “13 states cover GLP-1 medication for weight management as of August 2024” figure is superseded by the KFF January 16, 2026 tracker, which reports 13 state Medicaid programs covering GLP-1s for obesity under FFS as of January 2026 — but the composition of that 13-state group changed between August 2024 and January 2026 (Pennsylvania and California eliminated coverage; Tennessee and Missouri added).

EPSDT pediatric carve-in — IHCP Bulletin BT2023148 (under age 21)

Adults remain categorically excluded under 405 IAC 5-24-3(b)(1), but Indiana operates a documented age-stratified two-tier system in which members under age 21 may access GLP-1 weight-loss medications through the federal EPSDT mandate (42 U.S.C. § 1396d(r)). The operative primary source is IHCP Bulletin BT2023148 (October 31, 2023), titled “IHCP to cover weight-loss medications in select cases under EPSDT.” The verbatim bulletin text:

“The Indiana Health Coverage Programs (IHCP) may cover weight-loss medications for eligible Medicaid members under the age of 21 through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. The two drugs currently approved by the Food and Drug Administration (FDA) for weight loss that may be available for an EPSDT eligible member with an approved prior authorization (PA) are Wegovy (semaglutide) and Saxenda (liraglutide). The fee-for-service (FFS) PA vendor, Kepro, or attributed managed care entity (MCE) will review PA requests for these medications to determine medical necessity. Prescribing providers are encouraged to submit PA requests for FFS using Kepro’s Atrezzo Provider Portal. Requests are to be submitted using the generic codes J3490, J3590 and C9399, but it is imperative that the specific drug name be chosen in the associated questionnaire in the Atrezzo Provider Portal or clearly listed on the faxed PA form. Medical necessity determination for the FDA-approved weight-loss medications under EPSDT for members under the age of 21 will be on a case-by-case basis using peer-reviewed literature. Medical necessity reviews will take into account a particular member’s needs and clinical assessment. Additional guidance may be found in the EPSDT Services provider reference module. PA requests should include a diagnosis of morbid obesity with comorbid conditions and documentation of nutritional counseling and/or weight-loss programs and any pharmacological agents or interventions that have been used by the member. Reassessments of medical necessity for continued authorization will occur every six months.”

Five scope boundaries the article record must be clear on:

1. Age: under 21 only. Adults (age 21 and older) remain excluded by 405 IAC 5-24-3(b)(1) regardless of BMI, comorbidities, or prior failed interventions.
2. Eligible drugs: Wegovy and Saxenda only as named in the bulletin. Zepbound was FDA-approved November 2023 — after BT2023148’s October 31, 2023 publication. This article does not represent Zepbound as covered for pediatric obesity through EPSDT without an updated primary-source citation.
3. Criteria are more restrictive than the FDA label. The bulletin requires “morbid obesity with comorbid conditions” plus documented nutritional counseling and prior pharmacological interventions — more gatekeeping than the FDA label for Wegovy (which generally allows BMI ≥ 95th percentile for ages ≥ 12 with no documented prior-failure requirement).
4. Reassessment every six months — tighter than the one-year T2D reauthorization cycle in the OptumRx GLP-1 PA Criteria document.
5. MCE-specific PA criteria apply. Each MCO (Anthem, CareSource, MDwise, MHS Indiana) establishes its own PA requirements and billing criteria for EPSDT weight-loss drugs within the managed-care delivery system. Contact the assigned MCO for managed-care members; the bulletin’s FFS criteria are not universally operative.

The PA codes used for EPSDT weight-loss submissions (J3490, J3590, C9399) are generic medical-benefit codes, not pharmacy-benefit NDC codes — because Wegovy and Saxenda in the EPSDT context are reviewed as case-by-case medical-necessity determinations, not as standard point-of-sale pharmacy adjudications. The bulletin references Kepro as the FFS PA vendor at the time of publication (October 2023); subsequent IHCP bulletins (BT202538, BT202572) reference OptumRx as the operational PBM for FFS pharmacy claims. FFS EPSDT weight-loss PA should be confirmed with the current OptumRx Clinical and Technical Help Desk at 855-577-6317.

T2D PA criteria — Mounjaro step-therapy and the MASH / PCOS carve-outs

Adults with a confirmed type-2 diabetes mellitus diagnosis may access preferred GLP-1 RAs (liraglutide AG, Ozempic, Trulicity, Victoza) with PA through the OptumRx GLP-1 RA / GIP / Combination Agents PA Criteria (effective April 15, 2025). The targeted-products list is: Bydureon BCise, Byetta, exenatide, liraglutide (AG and generic Victoza), Mounjaro, Ozempic, Rybelsus, Soliqua, Trulicity, Victoza, Xultophy. Wegovy and Zepbound are absent from this list (they have separate PA criteria documents gated on T2D for adult members).

Initial authorization criteria for all agents require: (1) age ≥ 18 (Trulicity and Victoza extend to age ≥ 10 for pediatric T2D), (2) documented T2D confirmed by chart or claims history, (3) baseline HbA1c within the past 90 days with submitted lab documentation, (4) trial of metformin for at least 90 days within the past 120 days OR documented intolerance/contraindication, (5) no concomitant DPP-4 inhibitor-containing agent (or a 45-day transition period), and (6) no concurrent use of another GLP-1 RA. Initial authorization: up to 6 months. Reauthorization: up to 1 year, contingent on documented HbA1c reduction from baseline OR medical justification with chart support.

Mounjaro step-therapy is the most restrictive element in the PA criteria. Mounjaro (non-preferred) requires trial and failure of two different preferred GLP-1 RA agents, at least one of which must be Ozempic or Trulicity, at optimized dose (Ozempic 2 mg/week; Trulicity 4.5 mg/week; Victoza 1.8 mg/day; Byetta 10 mcg twice daily) for at least 90 days each — or medical justification over all four preferred agents. Critically:

“…any medical justification regarding intolerance or adverse effects must be supported by documentation within submitted chart notes, gastrointestinal adverse effects are not considered an intolerance as they are expected class effects.”

A patient who tolerates only Mounjaro due to a perceived better GI dose-titration profile cannot use that as step-therapy justification in Indiana — Indiana writes the GI-class-effect carve-out into the criteria verbatim.

Ozempic has a second qualifying pathway: MASH or MASLD with confirmed fibrosis (FAST ≥ 0.67; FIB-4 2.67–3.47 for age ≥ 35; MRE ≥ 3.3 kPA; biopsy; MAST ≥ 0.242) plus a specialist consultation (endocrinologist, gastroenterologist, or hepatologist) and prescriber attestation of specific exclusion conditions. This is a semaglutide-MASH pathway, not a Wegovy-MASH pathway — Wegovy is non-preferred and its adult coverage through Indiana Medicaid is blocked by 405 IAC 5-24-3(b)(1) regardless of the MASH indication.

Victoza has a third qualifying pathway: polycystic ovary syndrome (PCOS) with metformin trial or contraindication. The PCOS pathway requires a documented PCOS diagnosis and is not a backdoor weight-loss route — PCOS is an endocrine disorder whose diagnostic criteria do not include obesity as a required feature.

2025–26 Indiana legislation — HB 1202, HB 1138, SB 282

HB 1202 (Shackleford, 2025) — did not advance

Indiana House Bill 1202 (“Medicaid coverage for treatment of obesity,” IC 12-15-5-22) was introduced by Rep. Robin Shackleford on January 8, 2025 and referred to the House Committee on Public Health the same day. The verbatim bill digest:

“Synopsis: Medicaid coverage for treatment of obesity. Requires Medicaid coverage for the treatment of obesity, including specified services and medication approved by the federal Food and Drug Administration. Requires written notice regarding the coverage to be provided annually to Medicaid recipients, providers, and prescribers. Effective: July 1, 2025.”

Section 1 of the introduced version would have added IC 12-15-5-22, requiring coverage for bariatric surgery, nutrition counseling, intensive behavioral therapy, prevention and wellness services, and “any medication approved by the federal Food and Drug Administration for chronic weight management,” with criteria not more restrictive than the FDA label. The bill would also have required unrestricted access to covered medications (subject only to medical necessity review on the same basis as other covered conditions) and an annual written notice to recipients, providers, and prescribers.

HB 1202 did not advance from the House Committee on Public Health during the First Regular Session of the 124th General Assembly (which ended in late April 2025). The Obesity Action Coalition submitted a support letter to Rep. Shackleford on January 27, 2025. The bill is not active in the 2026 Second Regular Session.

HB 1138 (Shackleford, 2025) — did not advance

Indiana House Bill 1138 (“Coverage for obesity treatments,” IC 5-10-8-28) was introduced concurrently and referred to the House Committee on Insurance on January 8, 2025. Unlike HB 1202 (which addressed IHCP), HB 1138 would have required Indiana state employee health plans to cover anti-obesity medication and intensive behavioral therapy for eligible individuals with an obesity diagnosis. It also did not advance from committee — a result corroborated by the November 2025 SPD Torch newsletter announcement that the state employee plan was dropping GLP-1 weight-loss coverage effective January 1, 2026 (the opposite outcome from what HB 1138 would have mandated).

SB 282 (Charbonneau, 2026) — supply-side only, not Medicaid

Indiana Senate Bill 282 (“Compounding drugs and medical spas,” IC 16-42-22.5 + IC 25-26-13.7) was introduced January 12, 2026 and passed the legislature on February 26, 2026. Effective July 1, 2026; medical-spa registration with the Indiana Board of Pharmacy begins January 1, 2027. SB 282 is a supply-side bill — it restricts bulk-drug-substance compounding (including compounded GLP-1s) and requires medical-spa registration. It does not alter IHCP coverage, does not amend 405 IAC 5-24-3, and is not a Medicaid coverage statute. Its relevance to this article is that it regulates the cash-pay compounded-GLP-1 market that operates parallel to and outside of Indiana Medicaid.

The 2026 Second Regular Session of the 124th General Assembly adjourned Sine Die in late February 2026 without GLP-1 obesity Medicaid expansion legislation. The dominant Medicaid bill of the 2026 session was SB 1 (eligibility verification and work requirements), not coverage expansion. No Indiana bill currently before the 124th General Assembly would mandate IHCP coverage of GLP-1s for adult chronic weight management.

Indiana state employee plan — distinct from IHCP, dropped coverage January 1, 2026

The Indiana State Personnel Department (SPD) state employee health plan is a separate plan from IHCP. It is administered through CVS Caremark (a different PBM from OptumRx, which administers IHCP pharmacy claims). The State Personnel Department’s “Open Enrollment Edition Torch” newsletter of November 2025 states verbatim:

“GLP-1 drugs for weight loss. Effective January 1, GLP-1 drugs used for weight loss will no longer be covered under the State’s pharmacy benefit. Employees currently utilizing a GLP-1 drug for weight loss will receive a letter from CVS Caremark notifying them of the change. For those currently using GLP-1 drugs for weight loss purposes: Talk with your doctor: This change in the State’s coverage does not mean you should stop taking your medication. Check with your doctor to determine if another covered medication, such as Phentermine or Xenical, will work for you.”

Three distinctions from IHCP that this article maintains throughout:

• IHCP (Indiana Medicaid): OptumRx PBM. 405 IAC 5-24-3(b)(1) categorically bars anorectics and any agent used to promote weight loss. Phentermine and Xenical are NOT covered alternatives for adult Medicaid members (they are themselves barred by the same exclusion). Continuous adult exclusion predating the 2014 Saxenda approval.
• Indiana state employee health plan: CVS Caremark PBM. Phentermine and Xenical are listed as covered alternatives. GLP-1 weight-loss coverage terminated January 1, 2026 — a contemporary contraction in the same cycle as Pennsylvania Medicaid’s termination.
• Governing authority: IHCP is governed by IC 12-15 and 405 IAC. The state employee plan is governed by IC 5-10-8. They are legally and administratively distinct.

PBM (OptumRx FFS) and the four-MCO statewide SUPDL carve-out

Indiana operates a statewide uniform pharmacy carve-out — the single most structurally distinctive feature of its pharmacy benefit architecture and one of only two such carve-outs verified in this series (the other is Tennessee). All four IHCP contracted MCOs as of 2026 — Anthem Blue Cross and Blue Shield, CareSource, MDwise, and Managed Health Services (MHS Indiana, a Centene subsidiary) — defer pharmacy benefits to the OptumRx-administered statewide IHCP SUPDL. There is no MCO-specific PDL override for weight-management indications because the underlying SUPDL excludes the indication via 405 IAC 5-24-3(b)(1).

FFS PBM contact: OptumRx Clinical and Technical Help Desk, 855-577-6317 (fax 855-577-6384). This is the PA submission, status inquiry, and exception-request contact for FFS pharmacy prior authorizations, including all GLP-1 RA class agents. For managed-care members, contact the assigned MCO.

Gainwell Technologies operates the IHCP non-pharmacy claims platform and bulletin publication infrastructure (the in.gov/ medicaid/providers bulletin archive) but is not the pharmacy PBM. Do not call Gainwell for pharmacy PA inquiries.

The CareSource April 1, 2026 PDL confirms the statewide carve-out architecture: Zepbound listed as Tier 2 / PA under “INCRETINMIMETICS”; Ozempic, Trulicity, Victoza listed with Tier 2 / PA / QL; verified absence of Wegovy and Saxenda from the body of the formulary (the “ANTI-OBESITY DRUGS” section header exists in the table of contents but contains no enumerated entries in the body).

MHS Indiana’s PDF on the Centene website is dated January 15, 2019 and should not be cited as current operational policy. Its legacy verbatim exclusion of “Drugs prescribed for weight loss (with the exception of Orlistat)” is historically informative — Indiana MCOs excluded weight-loss drugs before the SUPDL carve-out was formalized — but current operational pharmacy benefits are administered through the statewide IHCP SUPDL.

Comparison with the 15 prior states in this series

Indiana is the only state in the series with the specific combination of (1) state administrative code anchor at the same tier as Illinois, (2) EPSDT pediatric carve-in, and (3) Zepbound preferred on the SUPDL. No other state in the series has all three.

Excluded populations — HIP, Hoosier Healthwise, Hoosier Care Connect distinctions

Indiana administers IHCP across four programs, each with distinct benefit structures that interact with the GLP-1 exclusion differently:

• Hoosier Healthwise (HHW): Children and pregnant women, including Package C (CHIP for children up to age 19). GLP-1 weight-loss agents are excluded for adults. For members under age 21, the EPSDT carve-in (BT2023148) applies with PA through the attributed MCE.
• Healthy Indiana Plan (HIP): The Section 1115 waiver expansion for adults ages 19–64 up to 138% FPL, with the POWER Account contribution structure. GLP-1 weight-loss agents are excluded for all HIP members (HIP Plus and HIP Basic) under 405 IAC 5-24-3(b)(1). Additionally, HIP Basic members do not have coverage for bariatric surgery (CareSource April 1, 2026 PDL verbatim: HIP Basic excludes “bariatric surgery, Temporomandibular Joint (TMJ) Disorders, or rides”). HIP Plus members retain bariatric surgery coverage subject to medical necessity.
• Hoosier Care Connect: Aged, blind, and disabled members (SSI-linked). GLP-1 weight-loss agents are excluded. T2D GLP-1 coverage follows the statewide SUPDL and PA criteria.
• Indiana PathWays for Aging: Long-term services and supports managed-care program. Pharmacy benefits follow the statewide SUPDL. GLP-1 weight-loss agents excluded.

The uniform statewide SUPDL carve-out means there is no benefit to a member in a different IHCP program with respect to weight-management GLP-1 coverage — the exclusion applies across all programs uniformly. The only age-stratified distinction is the EPSDT pediatric carve-in for under-21 members.

Patient action steps and appeal pathway

Indiana Medicaid does not cover GLP-1 receptor agonists for adult chronic weight management. That is a policy-level determination grounded in 405 IAC 5-24-3(b)(1). A fair-hearing appeal cannot overturn a policy-level exclusion — the same limitation that applies in Illinois, New Jersey, and other regulatory-exclusion states in this series.

For adult IHCP members with weight-management goals, the realistic access pathways under current Indiana policy are:

1. T2D indication: If you have a confirmed type-2 diabetes mellitus diagnosis, GLP-1 RAs (Ozempic, Trulicity, Victoza, liraglutide AG as preferred; Mounjaro with step-therapy) are accessible via PA through OptumRx (855-577-6317). Ensure your prescriber submits a baseline HbA1c within the past 90 days with lab documentation and documents any prior metformin trial (90 days within the past 120 days) or metformin intolerance.
2. MASH / MASLD: Ozempic (semaglutide) has a MASH / MASLD carve-out in the Indiana GLP-1 PA criteria if you have confirmed fibrosis by the listed scoring methods and a specialist consultation. This requires documentation of the specific fibrosis score and prescriber attestation of specified exclusion conditions.
3. PCOS (Victoza only): Victoza (liraglutide) has a PCOS indication pathway in the PA criteria with a documented PCOS diagnosis and metformin trial.
4. Under age 21 (EPSDT): Members under 21 with morbid obesity plus comorbid conditions may request PA review through the attributed MCE (for managed-care members) or OptumRx (for FFS) using medical-benefit codes J3490 / J3590 / C9399. PA requests must include morbid-obesity diagnosis, documented prior nutritional counseling and weight-loss programs, and prior pharmacological interventions.
5. Fair hearing (procedural appeals only): To appeal an adverse benefit determination, file within 33 days of the date on the notice, or request a State fair hearing within 120 calendar days. Mail to: Office of Administrative Law Proceedings — FSSA, 100 N. Senate Avenue, Suite N802, Indianapolis, IN 46204. A fair hearing is appropriate for adjudication errors (misread diagnosis codes, missing documentation) but cannot change the underlying 405 IAC 5-24-3(b)(1) policy. Indiana Legal Services Inc. (ilsi.org) provides free representation in Medicaid hearings for qualifying individuals.

Cash-pay context: Indiana is the structural end-state for cash-pay compounded GLP-1 demand: a state with a hard adult exclusion, no MACE or OSA carve-back-in for GLP-1 weight management, a preferred Zepbound on the PDL that is nonetheless inaccessible for obesity, and a state employee plan that simultaneously dropped coverage January 1, 2026. Adult Hoosiers who cannot qualify through a T2D, MASH, or PCOS pathway face the full list-price or compounded market for GLP-1 access. SB 282 (effective July 1, 2026) will regulate the compounding supply side — monitor for implementation guidance from the Indiana Board of Pharmacy beginning January 1, 2027.

The federal CMS BALANCE Model (“Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth”) creates a voluntary state opt-in pathway for Medicaid GLP-1 anti-obesity coverage beginning May 2026; the state Medicaid agency notification deadline is July 31, 2026. No FSSA or OMPP statement of intent to participate in BALANCE has been made publicly as of May 10, 2026. This article does not represent Indiana as a BALANCE Model participant.

Related research

• Illinois Medicaid GLP-1 coverage (2026): the strictest-exclusion state — Pattern #5 closest twin to Indiana. Both anchor in state administrative code anorectic-drug language (89 IAC § 140.441(b) vs. 405 IAC 5-24-3(b)(1)); Indiana distinguished by Zepbound-preferred anomaly + EPSDT pediatric carve-in.
• Tennessee Medicaid GLP-1 coverage (2026): positive-coverage expansion — Pattern #13, the mirror-image state: same 2025 legislative session, opposite outcome. TennCare expanded coverage via Sequence 10-34-25; Indiana HB 1202 died in committee.
• Complete GLP-1 medication list 2026 — full FDA-approved drug reference covering every GLP-1 RA, GIP/GLP-1 RA, and combination agent including Zepbound, Wegovy, Ozempic, Mounjaro, Saxenda, Victoza, Trulicity, and Rybelsus with indications and dosing.
• GLP-1 pricing index 2026 — cash-pay and compounded market analysis. Indiana is a structural cash-pay funnel state: adult Medicaid exclusion + no MACE/OSA carve-back-in + Zepbound preferred but inaccessible for obesity creates the compounded-GLP-1 demand pool this index tracks.
• GLP-1 insurance coverage at the 10 largest US insurers
• GLP-1s for PCOS — evidence review (Victoza PCOS pathway in Indiana PA criteria is anchored to this indication)
• State Medicaid GLP-1 coverage hub — all 21 verified states in the series + 50-state grid
• Kentucky Medicaid GLP-1 coverage (2026): Pattern #21 — nullified-amendment exclusion state + KEHP-Medicaid jurisdiction inversion — The KEHP-Medicaid jurisdiction inversion comparison to Indiana. Indiana Medicaid excludes GLP-1s for adult weight management (405 IAC 5-24-3(b)(1)) AND the Indiana state employee plan (CVS Caremark) dropped GLP-1 weight-loss coverage January 1, 2026 — both programs exclude. Kentucky Medicaid similarly excludes (907 KAR 23:010 Section 5(2)(a) upheld by SB 65 override April 14, 2026) BUT the KEHP state employee plan (Anthem + CVS Caremark) retains GLP-1 weight-loss coverage in 2026 at 25% coinsurance. KY Medicaid excludes + KEHP covers. IN Medicaid excludes + state employee plan dropped. Opposite-of-opposite outcomes in the same 2025–2026 policy cycle — the structural comparison that distinguishes the two states most sharply.

Last verified: May 10, 2026 — OptumRx Indiana Medicaid SUPDL V1.0 (December 1, 2025), GLP-1 RA/GIP/Combination Agents PA Criteria (April 15, 2025), IHCP Bulletins BT2023148 / BT202538 / BT202572, 405 IAC 5-24-3 (Cornell Law mirror), HB 1202 Fiscal Note (LSA), CareSource April 1, 2026 PDL, FSSA OALP appeals page. PDLs and PA criteria are updated on a quarterly or DUR-Board-cycle basis; verify current documents at in.gov/medicaid/providers before making any coverage determination.