Prescription coverage

Your HAP Empowered Medicaid plan covers drugs. There are no copays for covered drugs. You must use a pharmacy in the network to fill your prescriptions. You can find a pharmacy near you by searching our website.

For HAP Empowered Medicaid members (Medicaid, MIChild, Healthy Michigan Plan, Children’s Special Health Care Services), we use the Michigan Medicaid Common Formulary.

A formulary is a list of covered drugs. If you want to look at the drugs on the formulary, or search for a certain drug, you can search the list. It includes drugs from a pharmacy, not drugs from your doctor’s office or the hospital. The list includes prescription drugs and covered over-the-counter drugs. We also cover all drugs to help you stop smoking (e.g., nicotine gum, patches, lozenges, inhaler, Bupropion, Chantix). You can search by brand name or generic name.

HAP Empowered works with the state and other health plans to develop and update the list. We update it at least four times a year. We add new drugs and sometimes change the status of some drugs. When we make a change, we update the website so it’s available for you, providers and our Customer Service team. If we make a change to the drug list that affects you, we’ll send a letter to you and your doctor. This gives you time to talk to your doctor about the change.

Prescription coverage information

  • Formulary list and restrictions

    We cover up to a one-month supply for most medications, or less, if your doctor prescribes less. We cover a three-month supply of birth control pills. For safety reasons, you must use a certain amount of your medication before you can fill it again.

    We cover both brand and generics. If there’s a generic equal for a drug, we cover the generic, not the brand.

    Some drugs need approval before we’ll cover them. Prior authorization may be required when:

    • A drug has step therapy, which means you must try certain drugs before another drug is covered.
    • We need certain medical information from your doctor to make sure the drug is appropriate for treatment. For example, we might need diagnosis information, lab test results and history of medications.
    • A brand name drug is needed instead of the generic for a medical reason. For example, you’re allergic to a certain dye/color in the medication. These situations are rare.

    Some drugs have age restrictions or quantity limits. These are usually based on safety.

    All drugs are on the list are covered. If you need a drug not on the list, or there isn’t a good alternative on the list, you or your doctor can ask for an exception to the formulary. You can also ask us to waive restrictions or limits on a drug. You can request an exception at the website, or by telephone through Customer Service. Your doctor can send us an Exception Request form via fax or call us at (313) 664-8940, option 3.

    We work with your doctor for the information we need for prior authorization or exception requests. Your doctor will tell us why the drug is necessary.

    If we deny a drug request, we’ll send a letter to you and your doctor. The letter will tell you the reason why we denied the request. You have the right to appeal. If you want to appeal, you have 60 days from the date on the letter to appeal.

    To learn more, visit our appeals page:

    1. Go to Member resources.
    2. Click on the "Grievances and appeals" section at the bottom of the page.
  • Benefit limitations

    Some drugs are covered by the state of Michigan, not HAP Empowered Medicaid. When you go to the pharmacy, you should always take your HAP Empowered card and your mihealth Medicaid card. Your pharmacy knows about these drugs and will bill the state for these drugs.

    There are some drugs not covered by HAP Empowered or mihealth Medicaid, including:

    • Drugs not approved by the Food and Drug Administration
    • Drugs for cosmetic use
    • Experimental or investigational drugs
    • Weight gain or loss drugs
    • Combination cough/cold medications
    • Fertility drugs
    • Lifestyle drugs
    • Sexual or erectile dysfunction drugs
    • Replacement of lost or stolen medication
    • Any drug excluded for coverage by the state of Michigan

    Here’s some information available once you sign on securely.

    • Find your cost for a drug based on your Medicaid benefit (you pay zero)
    • Ask for an exception to the formulary
    • Find a pharmacy in the network
    • Find a pharmacy near you by using a zip code
    • Check to see if your drug has interactions with other drugs
    • Look up side effects of a drug
    • Check to see if your drug has a generic

    You can also get this information by calling Customer Service at (888) 654-2200 (TTY: 711). You can reach us 24/7.

  • Specialty drugs

    Specialty drugs are prescription drugs that need special handling, coordination with your doctor and patient education for safe and effective use. They can only be filled for up to a 30-day supply at a time. 

    These drugs are only available to members through Pharmacy Advantage, a specialty pharmacy service that mails them to your home. You must sign up for Pharmacy Advantage to get specialty drugs. These drugs may require prior authorization, meaning your doctor has to ask for permission for them to be covered by your plan.

    Conditions that may require treatment with specialty medications include:

    • Crohn’s disease
    • Hemophilia
    • Hepatitis B
    • Hepatitis C
    • Infertility
    • Immune disorders, such as Guillain-Barré syndrome or lupus
    • Kawasaki disease
    • Multiple sclerosis
    • Plaque psoriasis
    • Rheumatoid arthritis
    • Respiratory syncytial virus (RSV) (prevention)

    Our specialty pharmacy program focuses on medication safety. We want to make sure you receive safe, cost-effective medications and that you know how to take them correctly.

    How do I order specialty drugs?

    Our goal is to make sure you have access to the specialty drugs you need. We work with Pharmacy Advantage to provide medications that are not readily available at retail pharmacies.

  • Pharmacy Advantage Specialty Program

    Take advantage of these specialty drugs benefits through our Pharmacy Advantage partnership:

    • Direct outreach for counseling and educational materials
    • Support services to help you successfully use your specialty medication
    • Refill reminder service to help manage your medication schedule
    • Nursing and social support in collaboration with your doctor
    • Free supplies as needed for your prescribed disease management programs (e.g., syringes)
    • Prescription coverage verification completed for you

    Sign up for Pharmacy Advantage.

  • Formulary and forms

HAP Midwest Health Plan, Inc. is a wholly owned subsidiary of Health Alliance Plan (HAP). It is a Michigan nonprofit, taxable corporation.

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Customer Service

  • HAP Empowered Medicaid

    Call (888) 654-2200 (TTY: 711)

    Seven days a week,
    24 hours per day