Formulary Exception: Non Formulary Drugs

If the drug you are prescribing is not included on the IU Health Plans (HMO) (HMOPOS) Formulary, you should first contact the Provider Help Desk and ask if the drug is covered. If you learn that IU Health Plans (HMO) (HMOPOS) does not cover the drug, you have two options:

1. You can review the IU Health Plans (HMO) (HMOPOS) Drug Formulary and prescribe a similar drug that is covered by IU Health Plans.
2. You can ask IU Health Plans (HMO) (HMOPOS) to make an exception and cover the drug. Generally, IU Health Plans (HMO) (HMOPOS) will only approve your request for a non-formulary drug exception if based on your statement of medical necessity, the alternative drugs included on the IU Health Plans (HMO) (HMOPOS) formulary would not be as effective in treating the member's condition and/or would cause the member to have adverse medical effects.

We will give you and the member a decision within 72 hours of getting your statement of medical necessity for a standard exception request or 24 hours of getting your statement of medical necessity for an expedited exception request.

Non-Formulary Drug Restrictions:
Please note, if we grant your request to cover a drug that is not on our formulary, the member may not ask us to cover it at a lower cost-sharing level.

Also, due to a change in Medicare, most Medicare Drug Plans no longer cover erectile dysfunction (ED) drugs like Viagra, Cilais, Levitra, and Caverject.

Providers 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.

• Click here for the Physician's Coverage Determination Request Form. Fax or mail the completed form to:

IU Health Plans (HMO) (HMOPOS)
Prior Authorization Department
200 Stevens Drive
Philadelphia, PA 19113
Fax Standard: 1-866-429-2260
Fax Urgent: 1-866-497-1386

What can be done if a Coverage Determination is denied?
If IU Health Plans (HMO) (HMOPOS) denies the coverage determination the member or their representative has the right to request a redetermination appeal. Physicians and other prescribers, upon providing notice to the enrollee, have the right to request a redetermination appeal on a member's behalf. Please see our section on Appeals and Grievances for information about member appeal rights, or contact our Prescriber Appeals Department 8:00 a.m. - 8:00 p.m., seven days a week.

• Click here for more information on Appeals & Grievances.