Prescription Drug Authorization

As a new member to our plan you may be taking drugs that are not on our formulary or you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need prior authorization from us before we will pay for your prescription. You should talk to your doctor to decide if you should switch to another drug that we cover or request a formulary exception. During the first 90 days that you are a member of our plan, we may cover a limited amount of your current non-formulary drug therapy in certain cases while you talk to your doctor to determine the right course of action for you.

Click here to view the 2017 IU Health Plans (HMO) (HMOPOS) Comprehensive Drug Formulary.

To request a prior authorization or check the status of a prior authorization request submitted by your physician or other prescriber please contact us at 866-823-1016.

Click here for more information about appeals and grievances and coverage determinations.

Click here for more information about Part D prescription drug appeals and grievances.

Coverage Determinations & Exceptions

Members can request a coverage determination, exception, redetermination or appeal by completing and signing one of the forms below and mailing, faxing or emailing it to IU Health Plans (HMO) (HMOPOS), or by calling our Member Services department. Please contact us using one of the methods listed. You may also call Evolent Pharmacy at 866-823-1016. to get information about this process, to check on the status of your request, or to obtain an aggregate number of appeals and grievances for our plan.

Coverage Determinations and Exceptions: 

Fax: 855-397-8762

Phone: 866-823-1016

Email: MedicarePartD@evolenthealth.com

Mail:  IU Health Plans Pharmacy Services

Attn: Pharmacy Services
950 North Meridian St., Suite 600
Indianapolis, IN 46204

Redeterminations (Appeals):

Fax:   855-397-8762

Phone: 866-823-1016

Mail:  IU Health Plans 

Attn: Pharmacy Services
950 North Meridian St., Suite 600
Indianapolis, IN 46204

Medicare Prescription Drug Determination Information

The Medicare program offers a Coverage Determination request form for Medicare beneficiaries and/or prescribers to use to request prescription drug coverage. Use the link below to view this form and have your physician or other prescriber assist in completing this document. Please note, a physician supporting statement is required for all exceptions requests.

IU Health Plans (HMO) (HMOPOS) Prescription Drug Coverage Determination/Exception Request Form

Hospice Providers should utilize the link below to request a coverage determination or exception.

Hospice Provider Coverage Determination/Exception Request Form

If you or your prescriber submit a request for coverage that is denied and you do not agree with our decision, you may request an appeal (redetermination). Use the link below to view this form and have your physician or other prescriber assist in completing this document. Please note, a physician supporting statement is required for all exceptions requests.

IU Health Plans (HMO) (HMOPOS) Prescription Drug Coverage Redetermination Request Form

IU Health Plans (HMO) (HMOPOS) Prescription Drug Coverage Reconsideration Request Form

The Medicare program also offers forms to Medicare beneficiaries and provider for prescription drug determination or appeal requests. Use the links below to view this information on the Medicare website.

For Medicare Enrollees: Medicare Prescription Drug Determination Request Form

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For Medicare Providers: Medicare Part D Coverage Determination Request Form

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An IU Health Plans (HMO) (HMOPOS) member can appoint a person to act on his/her behalf. Print the form below, complete the required fields, and fax or mail it to us. Once we receive this completed request we will verify it, adjust our records accordingly, and speak to your appointed representative.

Appointment of Representative Form

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If you have any questions, please call Evolent Pharmacy at 866-823-1016.

Coverage Determinations and Exceptions:

Coverage Determination and Exception requests can be submitted to IU Health Plans using one of the methods below:

Fax:      855-397-8762

Phone: 866-823-1016

Email: MedicarePartD@evolenthealth.com

Coverage Determination and Exceptions requests sent by email which contain Protected Health Information (PHI) should be sent securely. All requests submitted by email are immediately received by IU Health Plans Pharmacy Services and processed according to the turnaround times provided in your Evidence of Coverage.

Mail:   IU Health Plans Pharmacy Services

Attn: Pharmacy Services
950 North Meridian St., Suite 600
Indianapolis, IN 46204

Online Form:

  1. Please select the appropriate coverage determination and exception form from above.
  2. Have your physician or other prescriber assist in completing the form.
  3. Save the form on your computer. If you do not wish to save personal health information on your computer, please use one of the other methods provided on this page.
  4. Use the online form provided below to upload the document and submit to IU Health Plans.

Redeterminations (Appeals):

Redetermination requests can be submitted to IU Health Plans using one of the methods below:

Fax: 855-397-8762

Phone: 866-823-1016

Mail:  IU Health Plans

Attn: Pharmacy Services
950 North Meridian St., Suite 600
Indianapolis, IN 46204 

Online Form:

  1. Please select the appropriate redetermination form from above.
  2. Have your physician or other prescriber assist in completing the form.
  3. Save the form on your computer. If you do not wish to save personal health information on your computer, please use one of the other methods provided on this page.
  4. Use the online form provided below to upload the document and submit to IU Health Plans.

 

Disclaimer

IU Health Plans is a Medicare Advantage organization with a Medicare contract. Continued enrollment depends on the contract between CMS and the Plan/Part D Sponsor remaining in effect, i.e. being renewed and not terminated. Other pharmacies/physicians/providers are available in our network. Product types include HMO and HMO-POS.

The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January 1 of each year.

Our hours of operation change throughout the year. We are available to take your call: Oct. 1 through Feb. 14 from 8am to 8pm, seven days a week and Feb.15 through Sept. 30 from 8am to 8pm, Monday through Friday, and 8am to 3pm on Saturday.