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

Member Information:

1. Print Member's Name (Last, First, Middle Initial)
2. Print Member's Date of Birth
3. Select correct letter to indicate the Member's gender (M-male, F-female)
4. Print the Member's ID number (located on the Member's ID card)
5. Print the Member's address and telephone number

Important: Claim Form must be signed. Unsigned forms cannot be processed and will be returned.

Prescription Information:

1. Indicate the number of prescriptions attached
2. Provide the total dollar amount paid for prescriptions
3. Provide Prescribing Physician's name, address and phone number.
4. Indicate reason you are submitting the claim(s).
5. Attach valid proof of prescription purchase. Include one of the following:

a. Patient history printout from the pharmacy, signed by the pharmacist;

OR

b. Prescription receipt which includes all information listed below:

• Pharmacy name and address
• Date filled
• Drug name, strength and NDC number
• Rx Number
• Quantity
• Days supply
• Price
• 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.

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