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Out-of-Network Pharmacy Claims: Direct Member Reimbursement

Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available. Before you fill your prescription at an out-of-network pharmacy, call Member Services to see if there is a network pharmacy in your area where you can fill your prescription. You may also access the IU Health Plans (HMO) (HMOPOS) Pharmacy Directory here. If you do go to an out-of-network pharmacy you may have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a direct reimbursement claim form. However, even after we reimburse you for our share of the cost, you may pay more for a drug purchased at an out-of-network pharmacy because the out-of-network pharmacy's price is higher than what a network pharmacy would have charged. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy as any amount you pay, consistent with the circumstances listed above, will help you qualify for catastrophic coverage

We will cover your prescription at an out-of-network pharmacy if at least one of the following applies:

  • If you are unable to obtain a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provides 24-hour service.
  • If you have to fill a prescription at an out-of-network pharmacy related to care for a medical emergency or urgent care.
  • If you are traveling within the United States and territories and become ill, lose or run out of your prescription drugs.
  • If you are trying to fill a prescription drug that is not regularly stocked at an accessible network pharmacy (including high cost and unique drugs).
  • If you are getting a vaccine that is medically necessary but not covered by Medicare Part B and some covered drugs that are administered in your doctor's office.

We cannot pay for any prescriptions that are filled by pharmacies outside of the United States and territories, even for a medical emergency.

Members who would like to request an Out-of-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:

Telephone: 1-866-907-1587
TTY/TDD: 1-800-743-3333

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.

Telephone:

1-866-412-8644

TTY/TDD: 1-866-412-8656


 
 
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Last Modified: Friday, December 20, 2013 3:25:21 PM
Pending CMS Approval
IU Health Plans is a Medicare Advantage organization with a Medicare contract.