Indiana University Health Plans
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Tiering Exception

The IU Health Plans (HMO) (HMOPOS) Formulary lists covered drugs according to 4 "tiers" or cost-sharing levels.

  • Tier 1 is the lowest cost-sharing level and applies to generic drugs only.
  • Tier 2 drugs are "preferred drugs" and have a higher cost-sharing level than tier 1 drugs.
  • Tier 3 is the non-preferred drug cost sharing level.
  • Tier 4 drugs have the highest cost sharing level because they are high-cost/ unique drugs.

If your drug is contained in our non-preferred tier (3), you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred drug tier (2). This would lower the amount you must pay for your drug. Your physician or other prescriber must provide a statement of medical necessity that explains why the lower tiered drug(s) in that drug class would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You cannot ask IU Health Plans (HMO) (HMOPOS) to cover a non-preferred drug at the generic drug cost sharing level. Also, you may not ask us to cover a tier 4 drug at a lower cost-sharing level.

If you are requesting an exception to the formulary rules you should submit a statement from your or other prescriber supporting your request.

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 3:25:48 PM
Pending CMS Approval
IU Health Plans is a Medicare Advantage organization with a Medicare contract.