Coverage Determinations & Exceptions - Provider

What is a Coverage Determination?
A coverage determination is any decision (an approval or denial) that IU Health Plans (HMO) (HMOPOS) makes when a member asks for coverage or payment of a drug that they believe IU Health Plans (HMO) (HMOPOS) should provide.

• Physicians or other prescribers and members can ask for a coverage determination.
• Members can also appoint someone (such as a relative) to request a coverage determination on their behalf.
• You can ask for a standard coverage determination, IU Health Plans (HMO) (HMOPOS) will give you and the member a decision in 72 hours.
• You can also ask for an expedited "fast" coverage determination if you or the member believes that their health could be seriously harmed by waiting up to 72 hours for a decision, IU Health Plans (HMO) (HMOPOS) will give you and the member an answer in 24 hours.

What type of Coverage Determination do I need?
There are different types of coverage determinations. Please click on the coverage determination type below for more information about the most commonly requested coverage determinations.

• Prior Authorization
• Formulary Exception - Prior Authorization
• Formulary Exception - Quantity Limits
• Formulary Exception - Non-Formulary Drug
• Tiering Exception

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 an expedited 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.