Formulary Exception: Quantity Limits

For certain drugs, IU Health Plans (HMO) (HMOPOS) may limit the number of doses that a member can receive during a set number of days. For example, IU Health Plans (HMO) (HMOPOS) provides 9 tablets per 30 day period for Imitrex. This may be in addition to a standard one month or three month supply. You can ask us to waive the limit and cover more. You must submit a statement of medical necessity on the member's behalf that states why the quantity limit 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.

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.