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Pharmacy forms and resources

Prescription drug coverage request forms

HAP Empowered MI Health Link

To file a grievance.

  1. Name a doctor, lawyer or family member as you Representative.
  2. Fill out the form.
  3. Mail to:

Express Scripts
P.O. Box 3610
Dublin, OH 43016-0307

For help, call (888) 654-0706 (TTY: 711). Call seven days a week. Call from 8 a.m. to 8 p.m.

Best available evidence 

CMS made the BAE policy in 2006.

Sponsors must set up true cost-sharing. It’s for low-income recipients. It’s when facts are not right.

Federal regulations at 42 CFR § 423.800 have requirements. They’re for Part D sponsors in the management of the low-income subsidy program. It has cutting cost sharing for subsidy-eligible people.

CMS may not show the right low-income subsidy status.

For more information, see the CMS website.

HAP Empowered MI Health Link is a health plan that contracts with both Medicare and Michigan Medicaid to provide benefits of both programs to enrollees.

H9712_Accepted 10/24/2022

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