Part D Forms

Below please find important forms to help you manage your IU Health Plans (HMO) (HMOPOS) prescription drug coverage.

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Some of our drugs require specialty prior authorization request forms. Please see the forms below for more information:

Antihistamines

Antipsychotics

Armodafinil

Aubagio

Botulinum Toxin

Cimzia

Cinryze

Daliresp

Enbrel

ESAs

Eylea & Lucentis

Fentanyl Citrate

General Authorization Form

Gilenya

Growth Hormone

Hepatitis C

Hospice

Humira

Hyaluronic Acid

Immunosuppressants

IVIG & SCIG

Lidocaine

Lupron

Lyrica

Memantine

Modafinil

Neulasta

Neupogen

Non-Formulary Medications

Orencia

PAH Agents

Prolia

Prostaglandin Analog

Quantity Limit Exception Request

Remicade

Rituxan

Simponi

Skeletal Muscle Relaxants

Stimulants

Suboxone, Zubsolv, & Buprenorphine

Tecfidera

Testosterone

Tiering Exception

Tysabri

Xeljanz

Zolpidem & Zaleplon

Zytiga & Xtandi

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.