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I
INDIANA UNIVERSITY
PRESCRIPTION PLAN
ADMINISTERED BY C
VS CAREMARK
FOR FULL-TIME ACADEMIC & STAFF EMPLOYEES,
IU RESIDENTS, AND STUDENTACADEMIC APPOINTEES
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CONTENTS
Foreword....................................................................................................3
Obtaining Prescription Drug Benefits..................................................4
Network Retail Pharmacy....................................................................4
Mail Order Pharmacy...........................................................................4
Specialty Pharmacy.............................................................................4
Covered Services......................................................................................5
Prior Authorization..............................................................................5
Formulary or Preferred Drug List.......................................................5
Step Therapy........................................................................................5
Specialty Pharmacy Network.............................................................5
Covered Prescription Drug Benets...................................................6
Non-Covered Prescription Drug Benets...........................................6
Deductible/Coinsurance/Copayment................................................6
Days Supply..........................................................................................7
Tiers.......................................................................................................7
Payment of Benets.............................................................................7
Schedule of Benefits................................................................................8
Anthem High Deductible Health Plan.................................................8
Anthem PPO $500 Deductible Plan...................................................8
Anthem IU Resident PPO Plan............................................................9
Anthem Student Academic Appointee (SAA) PPO Plan...................9
Definitions...............................................................................................10
Grievance & Appeals...............................................................................10
Notice of Privacy Practices....................................................................12
MANAGE YOUR PRESCRIPTIONS ONLINE
Log in to Caremark.com or the CVS Caremark app to:
• Request Mail Order rells quickly and conveniently
• Locate a network pharmacy
• Check drug availability and cost
• View prescription history
• Check drug interactions
• Learn more about the drugs you take
• Contact a pharmacist
To create your account, select “Register Now” on the home page
of Caremark.com or the Caremark app.
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Indiana University Prescription Plan
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3 Indiana University Prescription Plan
FOREWORD
This Indiana University Prescription Plan benefit document describes how to get prescription medications, what
medications are covered and not covered, and what portion of the prescription costs you will be required to pay.
CVS Caremark, the Pharmacy Benefit Manager (PBM), manages your prescription drug benefit under a contract
with Indiana University ("the plan"). CVS Caremark maintains the Preferred Drug list (also known as a Formulary),
manages a network of retail pharmacies, and operates the mail order and specialty drug pharmacies. CVS Caremark,
in consultation with the plan, also provides services to promote the appropriate use of pharmacy benefits, such
as review for possible excessive use, recognized and recommended dosage regimens, drug interactions, and other
safety measures.
Employees and dependents covered by Indiana University’s prescription drug benefit can use either retail
pharmacies or the CVS Caremark Mail Order Pharmacy. The benefit covers most prescription drugs and some OTC
items considered preventive under the Health Care Reform Act. Certain medications are subject to limitations and
may require prior authorization for continued use.
The benets described in this booklet are eective as of January 1, 2024.
QUESTIONS?
CVS Caremark may be contacted at:
CVS Caremark
P.O. Box 94467, Palatine, IL 60094-4467
T (866) 234-6952
Caremark.com
CVS Specialty: (800) 237-2767
24/7 TDD: (800) 231-4403
Indiana University may be contacted at:
IU Human Resources
2709 E. 10th Street, Ste 321
Bloomington, IN 47408
T (812) 856-1234 | F (812) 855-3409 | askhr@iu.edu
hr.iu.edu/benets
OBTAINING PRESCRIPTION DRUG
BENEFITS
RETAIL PHARMACY NETWORK
The CVS Caremark retail pharmacy network includes many chain and independent pharmacies including (but not
limited to) CVS, Walmart, Sam’s Club, Target, Kroger, and Williams Brothers. Walgreens is not part of the network for
IU plans. To search for participating pharmacies visit Caremark.com or call 866-234-6952.
You can receive up to a 90-day supply of many non-specialty medications through network retail pharmacies. To fill
your prescription at a network retail pharmacy, present your written prescription from your physician and your ID
card to the pharmacist. Alternatively, some physicians send prescriptions to pharmacies electronically, in which case
you will only need to present your ID card. You will be charged at the point of purchase for the applicable deductible
and/or copay/coinsurance amounts, and the pharmacy will submit your claim for you.
New in 2024—Caremark Cost Saver Powered by GoodRx. With the Caremark Cost Saver program, IU medical
plan members have automatic access to GoodRx pricing on participating generic medications. All you have to do
is present your Anthem ID card at your preferred network pharmacy. The program automatically compares the
covered benet price with the GoodRx price (when available) and charges you the lower of the two. For HDHP
members, the amount paid will automatically apply to your deductible and out-of-pocket maximum. For PPO
$500 Deductible plan members, the amount paid will automatically apply to your out-of-pocket maximum.
If you do not present your ID card, you will have to pay the full retail price of the prescription. If you do pay the full
charge, you can request reimbursement using the online claim system through your Caremark.com account, or
by submitting a paper Prescription Reimbursement Claim Form to Caremark. An original itemized pharmacy
receipt must be submitted with your claim that contains the following information. Please note that cash register
receipts can only be accepted for diabetes supplies.
• Metric quantity
• Pharmacy name and address or Pharmacy NCPDP number
• Total charge
• Patient’s name
• Day’s supply for your prescription
• Prescription number
• Date the prescription was filled
• Medicine NDC number (drug number)
MAIL ORDER PHARMACY
You can receive up to a 90-day supply of many non-specialty maintenance medications through the Mail Order
pharmacy. To begin Mail Order delivery, log in to your Caremark.com account or complete the CVS Caremark
Mail Order Form. You can mail written prescriptions from your physician, or have your physician fax or send the
prescription electronically to CVS Caremark. You will need to submit the applicable deductible, coinsurance and/or
copay amounts to CVS Caremark when you request a prescription or refill.
Medications are shipped standard delivery at no additional cost. You can track your prescriptions and order refills at
Caremark.com or by calling 866-234-6952. Registered pharmacists are available around the clock for consultation.
SPECIALTY DRUGS
Specialty medications are used to treat complex conditions, such as cancer, growth hormone deciency, hemophilia,
hepatitis C, immune deciency, multiple sclerosis, and rheumatoid arthritis. CVS Specialty oers therapy-specic
teams that provide an enhanced level of personalized service to patients with special therapy needs.
Specialty drugs are only covered through mail order, and must be lled through CVS Specialty, subject to a 30-day
supply, with the applicable deductible, coinsurance, or copay. Some specialty medications may qualify for third-party
copay assistance programs which could lower your out-of-pocket costs for those products. For more information or
to order your specialty medications, visit CVSSpecialty.com or call 800-237-2767.
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Indiana University Prescription Plan
5 Indiana University Prescription Plan
OUT-OF-NETWORK R
ETAIL PHARMACY
If you visit a non-network retail pharmacy, you are responsible for payment of the entire amount charged and will
need to submit a claim for reimbursement through CVS Caremark for consideration. You are responsible for the
applicable deductible, coinsurance, or copay. This is based on the Maximum Allowable Amount as determined by
CVS Caremark’s normal or average contracted rate with network pharmacies on or near the date of service.
COVERED SERVICES
PRIOR AUTHORIZATION
Prior Authorization may be required for certain prescription drugs (or the prescribed quantity of a particular drug).
Prior Authorization helps promote appropriate utilization and enforcement of guidelines for prescription drug benefit
coverage. At the time you submit a prescription, the pharmacist is informed of the Prior Authorization requirement
through the pharmacy’s computer system. CVS Caremark may contact your provider if additional information is
required to determine whether Prior Authorization should be granted. CVS Caremark communicates the results of
the decision to both you and your provider.
If Prior Authorization is denied, written notification is sent to both you and your provider. You have the right to appeal
through the appeals process. The written notification of denial you receive provides instructions for filing an appeal.
You, your provider, or pharmacist, may check with CVS Caremark to verify covered prescription drugs, any quantity
and/or age limits, prior authorization, or other requirements. To ask if a drug requires Prior Authorization, contact
CVS Caremark at the Customer Service telephone number on the back of your ID card.
FORMULARY OR PREFERRED DRUG LIST
The formulary (also known as a "preferred drug list") is a list of commonly prescribed medications that may be
covered by the plan. The formulary is designed to inform you and your physician about quality medications that,
when prescribed in place of non-formulary medications, can help contain the increasing cost of prescription
coverage while also providing a high quality of care.
You can request a copy of the formulary by calling CVS Caremark at 866-234-6952 or view the list online at
Caremark.com. The preferred drug list is subject to periodic review and amendment, and the inclusion of a drug or
related item on the preferred drug list is not a guarantee of coverage.
CVS Caremark may contact you or your prescribing physician to make you aware of preferred alternatives.
Therapeutic interchange may also be initiated at the time the prescription is dispensed. The therapeutic interchange
drug list is subject to periodic review and amendment. No change in the medication prescribed for you will be made
without you, or your physicians’ approval.
For questions or issues involving therapeutic drug substitutes, contact CVS Caremark at 866-234-6952.
STEP THERAPY
Step therapy protocol means that a member may need to use one type of medication—usually a more cost-effective
one—before trying another. If their physician approves, the patient will be given the more cost-effective medication
to try first. If the physician does not approve and prefers the non-preferred drug, prior authorization is needed.
SPECIALTY PHARMACY NETWORK
“Specialty Drugs” are (a) used to treat complex conditions such as cancer, growth hormone deficiency, hemophilia,
hepatitis C, immune deficiency, multiple sclerosis, and rheumatoid arthritis; (b) are typically injected, infused
or require close monitoring by a physician or clinically trained individual; or (c) have limited availability, special
dispensing and delivery requirements, and/or require additional patient support. CVS Specialty oers:
• Expedited scheduled delivery to the location you choose (your home, doctor’s oce, outpatient clinic), and free
supplies to administer your medication (e.g., needles, syringes).
• Individualized support from trained nurses and patient care representatives.
• 24/7 access to registered pharmacists for questions.
CVS Specialty must be used to ll specialty drug prescription orders, subject to a 30-day supply, with the applicable
deductible, coinsurance, or copay. For more information or to order specialty medications, call 800-237-2767.
COVERED PRESCRIPTION DRUG BENEFITS
Prescription drugs, unless otherwise stated below, must be medically necessary and not experimental/investigative,
to be covered. For certain prescription drugs, the prescribing physician may be asked to provide additional
information before CVS Caremark and/or the plan can determine medical necessity. The plan may, in its sole
discretion, establish quantity and/or age limits for specific prescription drugs. If your medication is in a category not
covered by the prescription drug benet, please check with your medical carrier as it may be covered by that benet.
Covered services will be limited based on medical necessity, quantity and/or age limits established by the plan, or
utilization guidelines. Covered prescription drug benets include:
• Certain OTC medications as indicated under the Affordable Care Act*
• Certain supplies and equipment are covered such as diabetic test strips, lancets, swabs, glucose monitors,
and inhaler spacers. If certain supplies, equipment or appliances are not available through the prescription
benefit, they may be available through the medical benefit.
• Contraceptive devices
• Contraceptive drugs: oral, transdermal, intravaginal, and injectable
• Non-insulin needles and syringes
• Immunizations covered under the Affordable Care Act*
• Influenza immunizations
• Injectable insulin and needles and syringes used for administration of insulin
• Injectables unless otherwise noted as benefit exclusions
• Prescription and some OTC smoking cessation drugs**
• Prescription legend drugs
• Prescription medical foods such as nutritional supplements, infant formulas, supplements for inherited
metabolic diseases (including PKU)
• Prescription vitamins including prescription fluoride supplements as well as those covered under the
Affordable Care Act*
NON-COVERED PRESCRIPTION DRUG BENEFITS
Non-covered prescription drug benefits include:
• Allergy sera
• Blood and blood plasma products except for hemophilia factors
• Compounds
• Drugs for treatment of sexual or erectile dysfunctions or inadequacies, regardless of origin or cause
• Drug treatment related to infertility
• Estriol compounds
• Experimental/Investigative drugs
• Medications used for cosmetic purposes only such as hair growth stimulants
• Over-the-counter drugs and vitamins, except insulin and those covered under the Affordable Care Act*
• Over-the-counter homeopathic or herbal medicines
*Certain prescription and OTC medications are considered preventive by the Aordable Care Act and are covered by the plan. A prescription is
required to obtain these preventive medications through your prescription benet.
** Many tobacco cessation prescriptions and nicotine replacement products are considered preventive and covered at 100% (no deductible) by
the plan. The maximum allowable benet for tobacco cessation medications on your preventive prescription drug list lled at retail or Mail Order
pharmacies is a 180-day supply every year. After you reach the drug-specic maximum allowable preventive benet, the deductible, coinsurance,
or copay will apply.
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Indiana University Prescription Plan
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DEDUCTIBLE/COINSURANCE/COPAY
Each prescription order may be subject to a deductible, coinsurance, or copay. If the prescription order includes
more than one covered drug, a separate deductible, coinsurance, or copay will apply to each drug.
The amount you pay for your prescription drugs will be no less than the minimum copay (unless the usual and
customary retail price is less than the minimum copay) and no more than the lesser of your scheduled copay/
coinsurance amount or the maximum allowable amount.
Please see the Schedule of Benefits for any applicable deductible, coinsurance, or copay. You are responsible for
all deductible, coinsurance, and copay amounts. If you receive covered services from a non-network pharmacy, a
separate deductible, coinsurance, or copay amount may also apply.
DAY’S SUPPLY
The number of day’s supply of a drug that you may receive is limited. The day’s supply limit applicable to
prescription drug coverage is shown in the Schedule of Benefits. Day’s supply may be less than the amount shown in
the Schedule of Benefits due to prior authorization, quantity limits, and/or age limits and utilization guidelines.
If you are going on vacation and you need more than the supply allowed for a retail prescription under this plan, talk
with your retail pharmacist. If your prescription is through Mail Order, call CVS Caremark Mail Order Pharmacy and
request an override for one additional refill. This will allow you to fill your next prescription early. If you require more
than one month of early refills, contact IU Human Resources at askhr@iu.edu or 812-856-1234.
TIERS
CVS Caremark classifies prescriptions by tiers:
generic (Tier 1), preferred (Tier 2) and non-preferred
(Tier 3). In the case of the IU SAA PPO and IU
Resident PPO plans, specialty medications are
classified as a fourth tier (Tier 4).
Under a traditional medical plan, your copay/
coinsurance amount may vary based on what tier
the prescription drug has been classified by the plan,
including covered specialty drugs. For high deductible
health plans (HDHPs) the deductible/coinsurance
amount does not vary based on tiers.
The determination of tiers is made based upon
clinical information, and, where appropriate, the cost
of the drug relative to other drugs in its therapeutic
class or used to treat the same or similar condition,
the availability of over-the-counter alternatives, and
certain clinical economic factors.
Tier Drug Type Cost
1 Generally includes generic prescription
drugs.
$
2 Generally includes preferred brand
name or generic drugs that, based
on their clinical information and cost
considerations, are preferred relative to
other drugs.
$$
3 Generally includes non-preferred brand
name or generic drugs that, based
on their clinical information and cost
considerations. are not preferred relative
to other drugs in lower tiers.
$$$
PAYMENT OF BENEFITS
The amount of benefits paid is based upon whether you receive the drug from a retail pharmacy, Mail Order
Pharmacy, Specialty Pharmacy, or a non-network retail pharmacy. It is also based upon the Tier classification for
the prescription drug or specialty drug. Please see the Schedule of Benefits for the applicable amounts, and for
applicable limitations on number of days supply.
The plan retains the right at its discretion to determine coverage for dosage formulations in terms of covered
dosage administration methods (for example by mouth, injections, topical or inhaled) and may cover one form of
administration and exclude or place other forms of administration on other tiers.
No payment will be made by the plan for any covered service unless the negotiated rate exceeds any applicable
deductible and/or copay/coinsurance for which you are responsible.
SCHEDULE OF BENEFITS
Please refer to the Covered Services section of this booklet for a more complete explanation of the specific services
covered by the plan. All covered services are subject to the conditions, exclusions, limitations, terms, and provisions
lifetime maximums or pre-existing condition limitations.
ANTHEM HIGH DEDUCTIBLE HEALTH PLAN (HDHP)
Service In-Network—Member Pays Out-of-Network—Member Pays
Retail Prescriptions
(Up to 90-day supply)
20% after deductible
Specialty Drugs are not covered at retail.
No deductible or coinsurance on most
contraceptives.
Reimbursed up to the Maximum
Allowed Amount or cost of
prescription, whichever is
less, after member cost-share
(deductible or coinsurance).
Mail Order (Up to 90-day supply)
Specialty Drugs (Up to 30-day supply)
Deductible (combined in-network and out-of-network prescription + medical):
• $1,900 employee-only/$3,800 all other coverage levels
• The deductible applies to all covered prescription costs (except preventive prescriptions).
Out-of-Pocket Maximum (combined in-network and out-of-network prescription + medical):
•
• All prescription drug costs paid by the employee apply towards the out-of-pocket maximum; once the member and/or
1 No deductible on preventive prescriptions. For drug list, visit hr.iu.edu/benefits/rx.html.
ANTHEM PPO $500 DEDUCTIBLE PLAN
Service In-Network—Member Pays Out-of-Network—Member Pays
Tier 1
(Generic)
Retail (30-day supply) —$8
Retail (90-day supply) —$20
Mail Order (90-day supply) —$20
50% coinsurance
plus amounts above
the network's discounted price
Tier 2
(Preferred Brand)
Retail (30-day supply) —$25
Retail (90-day supply) —$62
Mail Order (90-day supply) —$62
Tier 3
(Non-Preferred Brand)
Retail (30-day supply) —$45
Retail (90-day supply) —$112
Mail Order (90-day supply) —$112
Specialty Drugs
(30-day supply)
Tier 1 (Generic) —$20
Tier 2 (Preferred Brand) —$62
Tier 3 (Non-preferred Brand) —$112
No Coverage
Three-tier Prescription Copays: Within the brand and generic categories drugs are assigned a copay “tier” based on cost and therapeutic value
compared to other drugs. Tier 1 drugs are generics; Tier 2 are preferred brands; Tier 3 drugs include non-preferred brand drugs.
Deductible:
• No deductible applies
• No deductible or copay on most contraceptives
Out-of-Pocket Maximum (in-network prescription only):
• $7,050 individual/$11,700 family maximum
1 For a brand drug with a generic version available: member pays generic copay plus the cost difference between the brand and generic.
3 Medical expenses do not count toward prescription out-of-pocket maximum
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Indiana University Prescription Plan
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ANTHEM IU RESIDENT PPO PLAN
Service In-Network—Member Pays Out-of-Network—Member Pays
Tier 1
(Generic)
Retail (30-day supply) —$10
Retail (90-day supply) —$25
Mail Order (90-day supply) —$25
50% coinsurance
plus amounts above
the network's discounted price
Tier 2
(Preferred Brand)
Retail (30-day supply) —$25
Retail (90-day supply) —$60
Mail Order (90-day supply) —$60
Tier 3
(Non-Preferred Brand)
Retail (30-day supply) —$75
Retail (90-day supply) —$180
Mail Order (90-day supply) —$180
Tier 4
(Specialty Drugs)
Specialty (30-day supply only through Mail Order) —$150 No Coverage
Four-tier Prescription Copays: Within the brand and generic categories drugs are assigned a copay “tier” based on cost and therapeutic value
compared to other drugs. Tier 1 drugs are generics; Tier 2 are preferred brands; Tier 3 drugs include non-preferred brand drugs; Tier 4 drugs include
specialty drugs.
Deductible:
• No deductible applies
• No deductible or copay on most contraceptives
Out-of-Pocket Maximum (in-network prescription only):
•
1 For a brand drug with a generic version available: member pays generic copay plus the cost difference between the brand and generic.
3 Medical expenses do not count toward prescription out-of-pocket maximum
ANTHEM STUDENT ACADEMIC APPOINTEE (SAA) PPO PLAN
Service In-Network—Member Pays Out-of-Network—Member Pays
Tier 1
(Generic)
Retail (30-day supply) —$10
Retail (90-day supply) —$20
Mail Order (90-day supply) —$20
50% coinsurance
plus amounts above
the network's discounted price
Tier 2
(Preferred Brand)
Retail (30-day supply) —$40
Retail (90-day supply) —$80
Mail Order (90-day supply) —$80
Tier 3
(Non-Preferred Brand)
Retail (30-day supply) —$75
Retail (90-day supply) —$150
Mail Order (90-day supply) —$150
Tier 4
(Specialty Drugs)
Specialty (30-day supply only through Mail Order) —$150 No Coverage
Four-tier Prescription Copays: Within the brand and generic categories drugs are assigned a copay “tier” based on cost and therapeutic value
compared to other drugs. Tier 1 drugs are generics; Tier 2 are preferred brands; Tier 3 drugs include non-preferred brand drugs; Tier 4 drugs include
specialty drugs.
Deductible:
• No deductible applies
• No deductible or copay on most contraceptives
Out-of-Pocket Maximum (in-network prescription only):
•
1 For a brand drug with a generic version available: member pays generic copay plus the cost difference between the brand and generic.
3 Medical expenses do not count toward prescription out-of-pocket maximum
DEFINITIONS
Coinsurance
The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your
deductible.
Copay
A fixed amount (for example $8) paid for a covered service.
Deductible
A fixed amount that you must pay each policy year. This amount must be met before any benefits will be paid by
your insurance.
Mail Order
A convenient means of obtaining maintenance medications by mail. Covered prescription drugs are ordered directly
from the licensed Mail Order Pharmacy and shipped to your home.
Maintenance Medication
Drugs generally taken on a long-term basis for conditions such as high blood pressure and high cholesterol.
Member
Any person covered under the plan, including the employee, a spouse, or a child. Sometimes also referred to as
enrollee or participant.
Pharmacy
An
establishment licensed to dispense prescription drugs and other medications through a duly licensed pharmacist
upon a physician's order. A pharmacy may be a network provider or a non-network provider.
Prescription Legend Drug/Prescription Drug
A medicinal substance that is produced to treat illness or injury and is dispensed to patients. Under the Federal
Food, Drug, and Cosmetic Act, such substances must bear a message on its original packaging label that states
"Caution: Federal law prohibits dispensing without a prescription."
Specialty Drugs
High cost medications used to treat chronic, complex, and/or rare disease states generally requiring clinical
assessment to optimize safety and adherence. Specialty drugs are often, but not only, given by injection or infusion,
and may require special handling, storage, and/or administration. These drugs are covered only through CVS
Specialty Pharmacy.
GRIEVANCE & APPEALS
To formally lodge a complaint with CVS Caremark, call 866-234-6952. Your initial response will be addressed by a
Customer Service Representative.
Your concerns will be logged into CVS Caremark's Customer Service Contact System. Unresolved complaints will
be escalated to a customer service resolution expert or to a supervisor. You can also request that your issue be
escalated.
If your issue it sill not resolved to your satisfaction, you have the right to file a formal appeal either verbally by phone,
by mail, or by fax. You will receive a follow-up phone call and/or letter regarding resolution of your issue.
Telephone: File an appeal verbally at 866-234-6952.
Fax: File appeals via fax at 866-443-1172.
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Indiana University Prescription Plan
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NOTES
Indiana University Healthcare Plans Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this
information. Please review it carefully.
Effective Date: April 14, 2003
Updated: March 23, 2023
As the Plan Sponsor of employee health care plans, Indiana
University is required by law to maintain the privacy and security of
your individually identifiable health information. We protect the
privacy of that information in accordance with federal and state
privacy laws, as well as the university’s policy. We are required to
give you notice of our legal duties and privacy practices, and to
follow the terms of this notice currently in effect.
This notice applies to all employees covered under an IU-
sponsored health plan, but particularly those enrolled in IU self-
funded plans.
How the Plan May Use and Disclose Protected
Health Information about Members
P
rotected Health Information (PHI) is health information that relates
health care, or payment for provision of health care, whether past,
present or future and regardless of the form or medium, that
is received or created by the Plan in the course of providing benefits
under these Plans.
The following categories describe different ways in which Indiana
University uses and discloses health information. For each of the
categories Indiana University has provided an explanation and an
example of how the information is used. Not every use or disclosure
in a category will be listed. However, all of the ways Indiana
University is permitted to use and disclose information will fall within
one of the categories.
Treatment
Health information may be reviewed to provide authorization of
coverage for certain medical services or shared with providers
involved in a member’s treatment. For example, the Plan may obtain
medical information from or give medical information to
a hospital that asks the Plan for authorization of services on the
member’s behalf, or in conjunction with medical case management,
disease management, or therapy management programs.
Payment
Medical information may be used and disclosed to providers so
that they may bill and receive payment for a member’s treatment and
services. For example, a member’s provider may give a medical
diagnosis and procedure description on a request for payment made
to the Plan’s claim administrator; and the claim administrator may
request clinical notes to determine if the service is covered. Similarly,
a physician may submit medical information to a Business
Associate for purposes of administering wellness program financial
incentives. Medical information may also be shared with other
covered entities for business purposes, such
as determining the Plan’s share of payment when a member is
covered under more than one health plan.
Explanations of Payments may be mailed to the physical or email
address of record for the employee, the primary insured.
He
alth Care Operations
Health information may be used or disclosed when needed
to administer the Plan. For example, Plan administration may
include activities such as quality management, administration of
wellness programs and incentives, to evaluate health care provider
performance, underwriting, detection and investigation of fraud,
data and information system management; and coordination of
Genetic information will not be used or disclosed for health plan
underwriting purposes.
Medical information may also be used to inform members about
a health-related service or program, or to notify members about
potential benefits. For example, we may work with other agencies
or health care providers to offer programs such as complex or
chronic condition management.
Individuals Involved in Your Care or Payment of Care
Unless otherwise specified, the plan may communicate health
information in connection with the treatment, payment, and health
care operations to the employee and/or any enrolled individual who
is responsible for either the payment or care of an individual
covered under the plan.Also, when a member authorizes another
party in writing to be involved in their care or payment of care, the
Plan may share health information with that party. For example,
when an employee signs an authorization allowing a close friend to
make medical decisions on their behalf, the Plan may disclose
medical information to that friend.
Legal Proceedings, Government Oversight, or Disputes Health
information may be used or disclosed to an entity with health
oversight responsibilities authorized by law, including
HHS oversight of HIPAA compliance. For example, we may share
information for monitoring of government programs or compliance
with civil rights laws. Health information may also be disclosed in
response to a subpoena, court or administrative order, or
other lawful request by someone involved in a dispute or legal
proceeding.
Research
Health information may be used or shared for health research.
Use of this information for research is subject to either a special
approval process, or removal of information that may directly
identify you.
Uses & Disclosures Requiring Your Written
Authorization
In all situations, other than the categories
described above, we will
ask for your written authorization before using or disclosing
personal information about you. The Plan will not share member
information for marketing purposes, including subsidized
treatment communications, or the sale of member information
without written permission. Members can also opt-out of
fundraising communications with each solicitation. If you have
given us an authorization, you may revoke it at any time. This
revocation does not apply to any uses or disclosures already
made in reliance on the authorization.
12 Indiana University Prescription Plan
13 Indiana University Prescription Plan
Mental health information, including psychological or psychiatric
treatment records, and information relating to communicable
diseases are subject to special protections under Indiana
law. Release of such records or information requires written
authorization or an appropriate court order.
Member Rights Regarding Protected Health
Information
Right to Inspect and Copy
Members have the right to inspect and obtain a copy of the
Protected Health Information maintained by the Plan including
medical records and billing records.
To inspect and copy PHI, members must submit in writing a
request to the plan administrator. Requests to inspect and
copy PHI may be denied under certain circumstances. If a
member’s request to inspect and copy has been denied written
documentation stating the reason for the denial will be sent to the
member.
Right to Amend
Members have the right to request an amendment to PHI if
they feel the medical information is incorrect for as long as the
To request an amendment, members must submit requests, along
with a reason that supports the request, in writing to the plan
administrator.
The Plan may deny a member’s request for an amendment if it is
not in writing or does not include a reason to support the request.
Additionally, the Plan may deny a member’s request to amend
information that:
• Is not part of the information in which the member would be
permitted to inspect or copy;
• Is not part of the information maintained by the Plan
• Is accurate and complete
Right to an Accounting of Disclosures
Members have the right to an accounting of PHI disclosures during
the six years prior to the date of a request.
To request an accounting of disclosures, members must submit
requests in writing to the plan administrator. Requests may not
include permitted PHI disclosures made to carry out treatment,
payment or health care operations included in the six categories
listed above. The member’s written request must include a date or
range of dates and may not include any dates before the April 14,
2003, compliance date.
Right to Request Restrictions
Members have the right to request restrictions on certain uses and
disclosures of Protected Health Information to carry out treatment,
payment or health care operations. Members also have the right to
request a limit on the information the Plan discloses to someone
who is involved in the payment of your care; for example: a family
member covered under the plan.
The Plan is not required to agree to your request. To request
restrictions, members must submit requests in writing to the Plan.
Requests must include the following: (1) information the member
wants to limit; (2) whether the member wants to limit our use,
disclosure or both; and (3) to whom the member wants the limit to
apply, for example, disclosures to a spouse.
Right to Request Condential Communications
Members have the right to request that the Plan communicate
with them about health information in a certain way or at a certain
location. For example, asking that the Plan contact a member only
at work.
To request condential communications, members must submit
requests in writing to the health plan administrator and must
include where and how members wish to be contacted. The Plan
will accommodate all reasonable requests.
Right to Receive Breach Notication
If the Plan components or any of its Business Associates or the
Business Associate’s subcontractors experiences a breach of
health information (as dened by HIPAA laws) that compromises
the security or privacy of health information, members will be
notied of the breach and any steps members should take to
protect themselves from potential harm resulting from the breach.
Right to a Copy of This Notice
Members have the right to a copy of this Notice by e-mail.
Members also have the right to request a paper copy of this notice.
To obtain a copy, please contact the Privacy Administrator or visit
hr.iu.edu/benets/privacynotice.pdf.
Changes Made to This Notice
The Plan reserves the right to change this Notice. The Plan
reserves the right to make the revised or changed notice eective
for Protected Health Information the Plan already has about
members as well as any information received in the future.The
new notice will be available on our web site, upon request, or by
mail.
Right to File a Complaint
If a member believes that their privacy rights have been violated,
they may le a complaint to the Privacy Administrator with Indiana
University’s Health Care Plans, see contact information below.
Members may le a complaint with the U.S. Department of Health
and Human Services Oce for Civil Rights by sending a letter to:
200 Independence Avenue S.W., Washington, D.C., 20201; calling
1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/
complaints.
Indiana University will not retaliate against any member for ling a
complaint.
Contact Information
Members may contact the health plan with any requests,
questions or complaints.We will respond to all inquiries within 15
days after receiving a written request. The Plan will accommodate
all reasonable requests.
Privacy Administrator
2709 E. 10th Street, Ste 321
Bloomington, IN 47408
812-856-1234 | [email protected]
Personal Representatives
Members may exercise their rights through a personal
representative. This person will be required to produce evidence
of their authority to act on a member’s behalf before being given
access to PHI or allowed to take any action for a member. Proof of
this authority may be one of the following forms:
• A power of attorney notarized by a notary public;
• A court order of appointment of the person as the conservator
or guardian of the individual; or
• An individual who is the parent of a minor child.
