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Formulary Exception: Non Formulary Drugs

If your drug is not included on the IU Health Plans (HMO) (HMOPOS) Formulary, you should first contact Member Services and ask if your drug is covered. If you learn that IU Health Plans (HMO) (HMOPOS) does not cover your drug, you have two options:

  1. You can ask Member Services for a list of similar drugs that are covered by IU Health Plans (HMO) (HMOPOS). When you receive the list, show it to your physician or other prescriber and ask him or her to prescribe you one of the drugs from that list.
  2. You can ask us to make an exception and cover your drug. Your physician or other prescriber must submit a letter of medical necessity for you. Generally, IU Health Plans (HMO) (HMOPOS) will only approve your request for a non-formulary drug exception if the alternative drugs included on the IU Health Plans (HMO) (HMOPOS) formulary, would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

Non-Formulary Drug Restrictions:
Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to cover it at a lower cost-sharing level.

Also, due to a change in Medicare, most Medicare Drug Plans no longer cover erectile dysfunction (ED) drugs like Viagra, Cilais, Levitra, and Caverject.

Generally, we must make our decision within 72 hours of getting you or your physician’s or other prescribers' request for standard coverage determinations or 24 hours of getting you or your prescribing physician's request for an expedited coverage determination.

Members who would like to request a prior authorization or check on the status of a prior authorization request submitted by their physician or other prescriber should contact our Member Services Department 8:00 a.m. to 8:00 p.m., seven days a week:

Telephone: 1-866-907-1587
TTY/TDD: 1-800-743-3333
Fax Standard: 1-866-429-2260
Fax Urgent: 1-866-497-1386


IU Health Plans (HMO) (HMOPOS)
Prior Authorization Department
200 Stevens Drive
Philadelphia, PA 19113

Physicians and other prescribers who would like to submit a prior authorization request may either contact our Provider Help Desk at 1-866-907-7088, or use our physician's coverage determination form available below. Please answer all questions on the form and fax to the phone number listed on the form.

IU Health Plans (HMO) (HMOPOS)
Prior Authorization Department
200 Stevens Drive
Philadelphia, PA 19113

What can I do if my Coverage Determination is denied?
If IU Health Plans (HMO) (HMOPOS) denies your coverage determination you have the right to request a redetermination appeal. Please see our section on Appeals and Grievances for information about your appeal rights, or contact our Member Appeals Department 8:00 a.m. - 8:00 p.m., seven days a week.

Telephone:

1-866-412-8644

Fax: 1-866-412-8656


 
 
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Last Modified: Friday, December 20, 2013 3:24:01 PM
Pending CMS Approval
IU Health Plans is a Medicare Advantage organization with a Medicare contract.