Prescription Drug Authorization

New members to our plan may be taking drugs that are not on our formulary or  a drug that is on our formulary but the ability to get it is limited. For example, a prior authorization may be needed from us before we pay for a prescription. We advise our members to talk to their doctor to decide if they should switch to another drug that we cover or request a formulary exception. During the first 90 days of membership in our plans, we may cover a limited amount of current non-formulary drug therapy in certain cases while our members talk to their doctor to determine the right course of action.

Providers who would like to submit a prior authorization request may use our physician’s coverage determination form below. Please answer all questions on the form and fax to the number listed on the form. 

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What can be done if a Coverage Determination is denied?

If IU Health Plans (HMO) (HMOPOS) denies the coverage determination, the member or their representative has the right to request a redetermination appeal. Physicians and other prescribers, upon providing notice to the enrollee, have the right to request a redetermination appeal on a member’s behalf. Please see our section on Appeals and Grievances for more information below. 

Appeals and Grievances Information

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. The Medicare program offers a Coverage Determination request form for Medicare beneficiaries and/or prescribers to use to request prescription drug coverage. 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 a member or prescriber submit a request for coverage that is denied, they may request an appeal (redetermination). Use the link below to view and complete this form. Please note, a physician supporting statement is required for all exceptions requests.

IU Health Plans (HMO) (HMOPOS) Prescription Drug Coverage Redetermination 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.