COVID-19 Information & Updates

COVID-19 Coverage and Billing - Public Health Emergency Set to End

As previously announced, our COVID-19 billing rules and guidelines will remain in effect through the Public Health Emergency (PHE), which expired on Thursday, May 11, 2023. As a result, some of the rules and guidelines put into place in response to the PHE will now be reversed. This means that member cost share and benefit plan rules may apply to services that were previously covered at 100% during the PHE.

Commercial and Medicare Advantage Post PHE Vaccination and Testing Coverage:

  • COVID-19 Vaccination and Administration - Will continue to be covered as a preventative health benefit with no member cost share.
  • COVID-19 Lab Tests - Will be covered, but subject to member cost share.
  • OTC COVID-19 Tests - Will only be covered for our Federal Employee Health Benefits (FEHB) members.

If you have questions about your coverage and COVID-19 and telehealth related costs, please call member services using the numbers below:

Commercial: 866.895.5828

Medicare Advantage: 800.455.9776

Latest on COVID-19: Testing & Vaccines

IU Health has a COVID-19 Resource Center with the latest information on testing, vaccines and more at iuhealth.org/covid19.

COVID-19 Information & Updates

COVID-19 Coverage and Billing - Public Health Emergency Set to End

As previously announced, our COVID-19 billing rules and guidelines will remain in effect through the Public Health Emergency (PHE), which expired on Thursday, May 11, 2023. As a result, some of the rules and guidelines put into place in response to the PHE will now be reversed. This means that member cost share and benefit plan rules may apply to services that were previously covered at 100% during the PHE.

Commercial and Medicare Advantage Post PHE Vaccination and Testing Coverage:

  • COVID-19 Vaccination and Administration - Will continue to be covered as a preventative health benefit with no member cost share.
  • COVID-19 Lab Tests - Will be covered, but subject to member cost share.
  • OTC COVID-19 Tests - Will only be covered for our Federal Employee Health Benefits (FEHB) members.

If you have questions about your coverage and COVID-19 and telehealth related costs, please call member services using the numbers below:

Commercial: 866.895.5828

Medicare Advantage: 800.455.9776

Latest on COVID-19: Testing & Vaccines

IU Health has a COVID-19 Resource Center with the latest information on testing, vaccines and more at iuhealth.org/covid19.

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Formulary Resources

A prescription drug formulary is a list of drugs a Medicare Advantage plan covers. The IU Health Plans (HMO and HMO POS) formulary includes thousands of brand-name and generic medications. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. These drugs have been approved for coverage by the health plan and are also reviewed and approved by the Centers for Medicare and Medicaid Services (CMS), the agency that administers the Medicare Program. Some of the drugs that IU Health Plans (HMO and HMO POS) cover may require you to obtain prior approval.

Click on the link below to view any drugs that require prior authorization:

Click the link below to see a list of drugs that require step therapy:


Utilization Management

For certain prescription drugs, IU Health Plans (HMO and HMO POS) has additional requirements for coverage or limits on coverage. These requirements and limits ensure that members use these drugs in the most effective way and to control drug costs. A team of doctors and pharmacists developed these requirements and limits.

Examples of utilization management tools are described below:

  1. Prior Authorization: IU Health Plans (HMO and HMO POS) requires you to get prior authorization for certain drugs. This means that approval is required prior to coverage. If you do not get approval, we may not cover the drug.
  2. Quantity Limits: For certain drugs, IU Health Plans (HMO and HMO POS) limits the amount of the drug that we will cover per prescription or for a defined period of time.
  3. Step Therapy: In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both effectively treat a medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.
  4. Generic Substitution: When there is a generic version of a brand-name drug available, network pharmacies will automatically give you the generic version, unless your doctor has told IU Health Plans (HMO and HMO POS) that you must take the brand-name drug and have obtained a prior authorization.

You can find out if the drug you take is subject to these additional requirements or limits by looking in the Formulary. If your drug is subject to one of these additional restrictions or limits and your physician determines that you aren’t able to meet the additional restriction or limit for medical necessity reasons, you or your physician may request an exception (which is a type of coverage determination).

Drug Utilization Review

We conduct drug utilization reviews for our members to make sure that they are getting safe and appropriate medications. These reviews are especially important for members who go to more than one doctor and/or pharmacy for their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records.

During these reviews, we look for medication problems such as:

If we identify a medication problem during our drug utilization review, we will work with you and your doctor to correct the problem.

Indiana University Health Plans is a Medicare Advantage organization with a Medicare contract. Enrollment in an HMO or HMO POS plan from Indiana University Health Plans depends on the plan’s contract renewal with Medicare.

IU Health does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status, or any other characteristic protected by federal, state or local law.

For language assistance call 800.455.9776 (TTY/TDD 711).

H7220_IUHMA23487 M_2023 Accepted 9.28.2022

Last updated 10.01.2022