In Network Pharmacy Claims: Direct Member Reimbursement
Generally, when you go to a network pharmacy, your claim is automatically submitted to us by the pharmacy. However, if you do have to pay out-of-pocket for a Part D drug that you get from a network pharmacy, you can ask us to us to reimburse you for our share of the cost by submitting a claim form.
Members who would like to request an In Network Pharmacy Claim - Direct Member Reimbursement or check on the status of a claim already submitted should contact our Member Services Department 8:00 a.m. to 8:00 p.m., seven days a week:
Click here for the Medicare Prescription Drug Claim Form.
Please read the following instructions carefully, complete the form, and mail it to:
IU Health Plans (HMO) (HMOPOS)
Prior Authorization Department
200 Stevens Drive
Philadelphia, PA 19113
- Print Member's Name (Last, First, Middle Initial)
- Print Member's Date of Birth
- Select correct letter to indicate the Member's gender (M-male, F-female)
- Print the Member's ID number (located on the Member's ID card)
- Print the Member's address and telephone number
Important: Claim Form must be signed. Unsigned forms cannot be processed and will be returned.
- Indicate the number of prescriptions attached
- Provide the total dollar amount paid for prescriptions
- Provide Prescribing Physician's name, address and phone number.
- Indicate reason you are submitting the claim(s).
- Attach valid proof of prescription purchase. Include one of the following:
a. Patient history printout from the pharmacy, signed by the pharmacist;
b. Prescription receipt which includes all information listed below:
- Pharmacy name and address
- Date filled
- Drug name, strength and NDC number
- Rx Number
- Days supply
- Member's Name
Note: Claims missing any of the information above may be returned or payment denied.
Reason for the Request:
This section of the form is to be used to explain the reason for the reimbursement request.
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.