Prescription coverage

We cover up to a one-month supply for most medications, or less, if your doctor prescribes less. We cover a three-month supply for many drugs that are taken every day. This includes drugs to treat diabetes, asthma, high blood pressure, cholesterol and other conditions. We cover up to a twelve month supply of birth control pills, contraceptive patches and the vaginal ring. For safety reasons, you must use a certain amount of your medication before you can fill it again.

We cover both brand and generics. Sometimes, we only cover the brand. Other times, we cover the generic. Your pharmacy will give you the drug that’s covered. 

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 drug is on the list but there are other drugs that are preferred. 
• When the generic drug is covered, but the brand name drug is needed instead 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 on the list are covered. If you need a drug that's 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.

Are you new to Medicaid or HAP Empowered? We want to make sure you get the drugs you need. 

Are you taking a drug that’s not on the drug list, that has restrictions or requires approval? We’ll cover a temporary supply to make sure you get the care you need. This temporary supply is for drugs that you’ve already been taking.

• For most drugs, this will happen automatically at the pharmacy the first time you fill your drug with your new HAP Empowered card. 
• For some drugs, we’ll contact your doctor the first time the pharmacy sends us a claim for your drug. This is for safety reasons. This includes drugs for pain and drugs that need special monitoring.
• The following people can ask for a temporary supply:
  • You
  • Your doctor
  • Someone who has your permission to care for you
• You can request the supply by:
  • Calling Customer Service, your Care Manager or the HAP Empowered Pharmacy team.
  • Asking in writing.
• You can get this temporary supply for the first 90 days when you are new to HAP Empowered. This is for drugs that you’ve already been taking. We’ll cover up to a 30-day supply in the first 90 days with us. We call this a “transition” fill. After the drug is filled at the pharmacy, we’ll send a letter to you and your doctor. The letter has instructions about the temporary fill and what to do next.
• We’ll work with your doctor to use a drug on the list or to approve your drug if there’s not a drug on the list is not that’s right for you. 

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
• 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 at hap.org/Medicaid

• Find your cost for a drug based on your Medicaid benefit (you pay zero)
• Ask for a drug that is not on the list
• Find a pharmacy in the network
• Find a pharmacy near you by using a zip code
• Check to see if your drug has a generic and if it’s on the list

You can also get this information by calling Customer Service at (888) 654-2200 (TTY: 711). You can reach us 24 hours a day, seven days a week..

Specialty drugs are prescription drugs that need special handling, coordination with your doctor and patient education for safe and effective use.

We work with Pharmacy Advantage. If you want to use Pharmacy Advantage, you can sign up to get specialty drugs by mail. 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
• Immune disorders, such as Guillain-Barré syndrome or lupus
• Kawasaki disease
• Multiple sclerosis
• Plaque psoriasis
• Rheumatoid arthritis
• Respiratory syncytial virus (RSV) (prevention)

This  program focuses on safe use of drugs. We want to make sure you know how to take them safely and correctly.

Here are some of the services from Pharmacy Advantage:  

• We may call you or provide helpful booklets or information
• We’ll make sure you know how to use your medication
• We can remind you about refills and how to take your medication
• Nursing and social support to work with your doctor
• Free supplies as needed for your medications and your condition (e.g., syringes)
• We will check to confirm your coverage

Sign up for Pharmacy Advantage.

Formulary

• HAP Empowered formulary (list of covered drugs)
• 2023 Smoking Cessation Formulary

Forms

• Pharmacy reimbursement form
• Request for prior authorization form