All Other Plans: Understanding your Prescription Coverage
To ensure that you receive quality medications, HAP uses a drug formulary. A formulary is a list of covered drugs and their respective copay tier, selected by HAP in consultation with a team of health care providers which represents the prescription therapies believed to be a necessary part of a quality treatment program. Prescription drugs are a covered benefit for those members who have a prescription drug rider included in their coverage with HAP. The standard one month supply of prescription drugs is "up to a 30-day supply" but individual plans may vary.
If your physician prescribes a medication that requires prior authorization or is not listed on the HAP Drug Formulary then your physician will need to request an authorization in order to obtain coverage. Physician offices are familiar with this process.
For members with a three-tier drug benefit the copay tiers are as follows:
- Lowest tier- most generic prescription covered drugs
- Second tier- select brand prescription drugs
- Third tier- brand prescription drugs with lower cost alternatives, lifestyle prescription covered drugs (drugs for infertility, weight loss, erectile dysfunction), injectable drugs
Step Therapy
In some cases, our plans require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
Covered Medication
For your medication to be covered you will first need a prescription written by a HAP-affiliated physician. Take your prescription to an affiliated pharmacy to be filled.
Whenever an FDA approved generic drug is available, your prescription will be filled with the generic form of the medication. Generic equivalent drugs have been put through a rigorous, multi-step approval process from quality and performance to manufacturing and labeling by the FDA; HAP also reviews generic products for safety and effectiveness. Members who receive a brand drug when a generic equivalent is available will be responsible to pay the generic copayment plus the difference between the cost of the generic equivalent and the brand drug.
Benefit Limitations
The HAP Drug Formulary applies to drugs used in an outpatient setting. It does not affect medication used while in the hospital. The following are general drug coverage exclusions that apply to all members:
- Over-the-Counter (OTC) medications and their equivalents are not covered unless specified in the formulary or on the rider.
- Drug products used for cosmetic purposes are not covered.
- Experimental drugs and/or any drug products used in an experimental manner are not covered.
- Replacement of lost or stolen medication is not covered.
- Since the selected drug packages and coverage vary for each employer group, check your benefit package to verify your co-pays and exclusions. If you have questions regarding your prescription drug coverage, contact the HAP Client Services Department.
Maintenance Drugs
What are they?
Maintenance drugs are medications prescribed for chronic, long-term conditions and are taken on a regular, recurring basis. Examples of chronic conditions that may require maintenance drugs are: high blood pressure, high cholesterol, and diabetes.
HAP has developed a list of drugs classified as "maintenance drugs" based on the most prevalent chronic health conditions in our member population. Drugs placed on the Maintenance Drug List are well-established medications that have proven safety and efficacy and are considered first-line therapy options for the treatment of common chronic conditions. The majority of these drugs are now available as generic drugs.
How are Maintenance Drugs Dispensed?
Up to a 90-day supply is covered for drugs listed on the HAP Maintenance Drug List if filled at an eligible 90-Day HAP retail pharmacy or by using the Medco Home Delivery Service. Most major chains and many independent pharmacies are in the HAP 90-Day network. This applies to most strengths and oral dosage forms of the drugs listed (except where noted). Typically the charge for a 90-day supply is two copays but individual plans may vary.
Drugs not listed on the maintenance drug list will be limited to 30-day fills or may be charged two copays in cases where a 90-day supply may be approved and filled at mail order, but individual plans may vary.
In order to fill a 90-day prescription, the physician must write the prescription for a 90-day supply.
More Info About Maintenance Drugs >>
Medical Exceptions
For drugs that require a prior authorization:
If you need to obtain medically needed medication that is not on the formulary, prior authorization is required. HAP has a process in place for medical exceptions which requires your physician to apply in advance for authorization. Please contact your PCP for more information about medical exceptions and obtaining prior authorization.
Denial Process
When a drug is denied, you and your physician will be notified by letter within two business days of the date of denial. The denial letter gives the reason for denial and explains our appeal process for filing a grievance. An appeal must be filed within 24 months of the date of denial. A 72-hour Expedited Grievance Process is available when the drug is determined to be medically necessary by HAP.
To request an expedited appeal or for additional information, call the Client Services department at the phone number listed on your ID card. To file a grievance on a denied medication, please send your letter to the address listed below.
Grievance Mailing Address:
Health Alliance Plan
Attention: Associate Vice President
Client Services Department
2850 West Grand Boulevard
Detroit, Michigan 48202
|
