Pharmacy information

Learn if your drug has coverage restrictions or limits

HAP Empowered MI Health Link has special rules for some drugs. This means that you or your doctor must take extra steps for us to cover the drugs that require approval before we cover the drug. For some drugs, we want you to try certain drugs before we cover that drug. This is called step therapy. Some drugs have quantity limits or coverage requirements.

You can find all limits or restrictions by searching the drug list. To search, press Ctrl+F (Command+F for Mac) and type in the name of the drug. If your drug is on the list, the drug will be highlighted. You can see if there are limits or restrictions. If your drug is not on the list, you can ask us for an exception. If your drug has other restrictions or limits, you can ask for an exception. 

Formulary exceptions

You or your doctor can request an exception:

• if your drug is not on the list
• if the drug has a limit or restriction

If we approve a request for a drug not on the list, or we waive limits or restrictions, the drug will be covered at no copay.

Doctor’s supporting statement for a formulary exception

If you or your doctor requests an exception, we need a statement from your doctor verbally, or in writing. The statement tells us the medical reasons why you need the drug. The doctor may cite one or more of these reasons:

• For approval of a non-formulary drug there must be a treatment failure after an adequate trial of at least four (4) formulary drugs from the same therapeutic class as the requested drug. If four drugs with a similar mechanism of action are not available on the formulary, a trial of alternative formulary drugs that are acceptable to treat the member's condition is required, as clinically appropriate. For DAW requests a treatment failure after an adequate trial of all formulary drugs in the same therapeutic class as well as other classes that can be used to treat the member's medical condition, as clinically appropriate is required. Members must have a documented allergy or adverse event to one or more ingredients present in the generic formulation and that are absent in the brand. 
• The alternatives on our list of drugs we want you to try first were not effective for you, or they have already caused you harm, or might cause you harm.
• The number of doses in our limit were not effective in treating your condition. Or your doctor thinks they won't be as effective.

Request an exception

To request an exception or prior authorization, use the Medicare Part D Coverage Determination Request Form (PDF).

Your doctor must sign the form and send it to us. Your doctor should include all important medical information that supports the request. For example, chart notes, lab information. Your doctor can fax or mail it to:

HAP Empowered MI Health Link
Attn: Pharmacy Care Management
2850 W. Grand Blvd.
Detroit, MI 48202
Fax: (313) 664-8045

We will send you a letter to let you know if we approved the request, and for how long.

We will also send you a letter if we deny your request.

You have the right to request an appeal. Please see the grievances, appeals, determination and exceptions section of our member resources page to learn how to request an appeal.

Prior authorization

You must get approval before we cover the drug. We might need health information from your doctor. It may be a diagnosis for lab results. If you don't get prior authorization, we might not cover the drug.

• 2023 Prior Authorization (PDF)

Step therapy

We ask you to try one drug before we cover some other drug. If drug A and drug B both treat your health condition, your doctor may need to order drug A first. If drug A doesn’t work, we’ll cover drug B.

• 2023 Step Therapy (PDF)

Generic substitute

We have a transition program the same as 42 CFR §423.120(b)(3). It makes sure you have access to covered drugs.

We may give you a temporary supply of a drug. This is when your drug is not on the list or is limited in some way. This gives you time to talk to your doctor about getting the different drug or asking us to cover your drug.

To get a temporary supply of a drug, you must meet these rules:

The drug:

• is no longer on the list
• was never on the list
• now has limits

For Medicare Part D drugs:

• you were in the plan last year
• you are new to the plan
• you have been in the plan for more than 90 days and live in a long-term care place and need the drug right away

For Michigan Medicaid drugs, you are new to the plan. You can work with your doctor to choose a new drug or for an exception.

Current enrollees affected by drug list changes from one contract year to the next.

• View the 2023 transition policy (PDF)

• Part B (Medical Drug) Step Therapy (PDF)

• Your $75.00 quarterly allowance rolls over from quarter to quarter within the calendar year
• Your total yearly benefit maximum is $300.00
• You can pay out-of-pocket for items that go over the quarterly or $300.00 maximum 
• There are three ways to order your items:
  
  • Phone,
  • Mail or
  • Online
• You can order as many times as you like
• Orders are shipped to your address
• There is 2-day shipping on most items