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:

• 2025 Prior Authorization Criteria
• 2024 Prior Authorization Criteria

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

• 2025 Step Therapy Criteria
• 2024 Step Therapy Criteria

Medicare prescription drug coverage Determination form.

• Request for Medicare Prescription Drug Determination
• Request for Medicare Prescription Drug Redetermination
  
• Request for Medicare Prescription Drug Reconsideration

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:

• Possible medication errors
• Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
• Drugs that are potentially inappropriate because of the member’s age or gender
• Possible harmful interactions between drugs you are taking
• Drug allergies
• Drug dosage errors

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