Coverage Determinations & Exceptions - Member

What is a Coverage Determination?
A coverage determination is any decision (an approval or denial) that IU Health Plans (HMO) (HMOPOS) makes when you ask for coverage or payment of a drug that you believe IU Health Plans (HMO) (HMOPOS) should provide.

• You or your physician and other prescribers can ask for a coverage determination.
• You can also appoint someone (such as a relative) to request a coverage determination for you.
• You can ask for a standard coverage determination, IU Health Plans (HMO) (HMOPOS) will give you a decision in 72 hours.
• You can also ask for an expedited "fast" coverage determination if you or your physician or other prescriber believes that your health could be seriously harmed by waiting up to 72 hours for a decision, IU Health Plans (HMO) (HMOPOS) will give you an answer in 24 hours.

What type of Coverage Determination do I need?
There are different types of coverage determinations. Please click on the coverage determination type below for more information about the most commonly requested coverage determinations.

• Prior Authorization
• Formulary Exception - Prior Authorization
• Formulary Exception - Quantity Limits
• Formulary Exception - Non-Formulary Drug
• Tiering Exception
• In Network Pharmacy Claim - Direct Member Reimbursement
• Out-of-Network Pharmacy Claim - Direct Member Reimbursement

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.

• Click here for more information on Appeals & Grievances.
• Click here for the Redetermination Request Form