About Prescription Coverage
- Three-tier Prescription Drug Rider
- Drug Formulary
- Prior Authorization
- Step Therapy
- Covered Medication
- Benefit Limitations
- Medical Exceptions
- Denial Process
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.
For members with a three-tier prescription benefit the copay tiers are as follows:
- Lowest tier- most generic covered prescription 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
Some employers offer a Three-Tier Prescription Drug Rider that includes different copays for medications based on their category.
To find out if you have a Three-Tier Prescription Drug Rider, look at the copay box on your HAP ID card. On the right of your ID card is your copay information. There are three copays associated with prescription coverage:
- Tier 1 -- Generic Rx copay
- Tier 2 -- Pref. Rx copay
- Tier 3 -- Non Pref. Rx copay
Tier 3 medications include specialty drugs, lifestyle medications and brand name medications with lower cost alternatives. Next to each of these copay terms may be a numbered amount. This is your copay amount (010 means you have a $10 copay).
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, impotence, erectile dysfunction), injectable drugs
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. These providers represent the prescription therapies believed to be a necessary part of a quality treatment program.
The HAP Drug Formulary applies to drugs used in an outpatient setting. It does not affect medication used while in the hospital.
Certain clinical criteria must be met before some drugs are covered. If your doctor prescribes a medication that requires prior authorization or is not listed on the HAP Drug Formulary then your doctor must request an authorization in order to obtain coverage. Physician offices are familiar with this process.
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.
In order for your medication to be covered a prescription must be written by a HAP-affiliated doctor. 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.
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 copays and exclusions. If you have questions regarding your prescription drug coverage, contact HAP Client Services.
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.
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