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Patient Insurance Information Form

Print or email this form to patients who need to provide their insurance billing numbers (BIN, PCN, Member ID, Rx Group)

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Indiana Medicaid Plan Change Guide

Patient handout explaining how to switch Hoosier Healthwise, HIP, or Hoosier Care Connect plans. Includes MDwise transition info.

📄 Open Patient Handout
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Former MDwise Indiana Medicaid Patient Handout (Grayscale)

Print-optimized handout for former MDwise members explaining their coverage transition and March 23, 2026 deadline.

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Indiana Medicaid

IN
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IN Medicaid Formulary

Search Indiana Medicaid drug list with filters for tier, prior authorization, quantity limits, and step therapy

🔍 Search Formulary
✓ Contracted Plans
Plan Name Code Group Number Actions
✗ Not Contracted Plans
Plan Name Code Group Number Actions
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Illinois Medicaid

IL
✓ Contracted Plans
Plan Name Code Group Number Actions
✗ Not Contracted Plans
Plan Name Code Group Number Actions
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Commercial Insurance

COMM
✓ Contracted Plans
Plan Name Code Group Number Actions
✗ Not Contracted Plans
Plan Name Code Group Number Actions
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đŸˇī¸ Rugby/Major OTC Drug Lookup

OTC
â„šī¸ About Rugby/Major OTC Products
Search our comprehensive database of Rugby and Major brand OTC medications by NDC, product name, description, or therapeutic category.
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Utility Codes

UTIL
Description Code Usage Actions
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Quick References

REF
Title Content Actions
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CGM (Continuous Glucose Monitoring)

CGM
âš ī¸ CRITICAL: CGM Billing (as of 12/9/24)
Walgreens can process Medicare Part B for: Freestyle Libre 2 Plus, Freestyle Libre 3 Plus, Dexcom G6, Dexcom G7

📞 CGM Support Contacts

Walgreens CGM Helpdesk: 877-378-9787
AR Central (Chart Notes Fax): 866-353-7514
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Medicare Part B

MED-B

📋 Medicare Part B Overview

Covers medically necessary services, supplies, and durable medical equipment (DME). Requires Standard Written Order (SWO) for most items.

📞 Key Contact Numbers
â˜Žī¸

Walgreens Medicare Support Center

888-281-0590 - General Medicare Part B issues

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Supplemental Medicare Part B Support

888-380-4798 - Supplemental insurance issues

💉 Diabetic Testing Supplies

âš ī¸ Important Rules

  • Cannot be mailed/delivered to patients (except CGM receiver & supplies)
  • Proof of Delivery required - Patient or representative signature with relationship documented
  • SWO Required - Standard Written Order with ICD-10 code for diabetes
  • 5-Day Rule - If not available within 5 business days, must contact prescriber for alternate product
Item Usual Utilizer (Non-Insulin) Usual Utilizer (Insulin) High Utilizer Frequency
Test Strips & Lancets 100 per 3 months (1x daily) 300 per 3 months (3x daily) >1x daily (non-insulin)
>3x daily (insulin)
Lancet Device 1 per 6 months 1 per 6 months Same
Blood Glucose Monitor 1 per 5 years
đŸĸ Comm 📋 IN 📋 IL đŸ’ŗ Med-B 📊 CGM 🔧 Util 📚 Ref 🏠 Home
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