Page 20-21 - aso_member_kit

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Specialty Drugs –
These are prescription or medical drugs that require close monitoring for safety
and efficacy. For this reason HAP has contracted with Pharmacy Advantage, a specialty pharmacy from
which you can obtain specialty drugs. Specialty drugs require prior authorization, and Pharmacy
Advantage can help you and your doctor submit a request for prior authorization. You or your doctor
can contact Pharmacy Advantage at
(800) 456-2112
Covered Medication Facts
a. Copays and coinsurances for prescriptions are listed in your plan documents and on your ID card.
b. Coinsurance for your medical drugs is listed in your plan documents.
Maintenance Drugs
Your health plan offers selected generic drugs that are designated as “maintenance” because they
are commonly used for managing chronic diseases. Our members can get these maintenance
drugs at most retail pharmacies for a 90-day supply. You can visit our website at
to see if your drug is listed on the HAP maintenance drug
You can also get a 90-day supply of most oral medications from our mail order pharmacy, Pharmacy
Advantage. The charge for a 90-day supply is normally two copays but may vary for some groups. Your
doctor would need to write your maintenance prescriptions for a 90-day supply.
The following are not covered:
1. Over-the-counter (OTC) medications, unless specified on the formulary
2. Dietary food or food supplements
3. Drug products used for cosmetic purposes
4. Experimental drugs and/or any drug products used in an experimental manner
5. Replacement of lost or stolen medication
6. The cost of prescriptions filled at non-plan pharmacies
Affiliated Pharmacy Network
Most major drugstore chains in southeast Michigan are in your pharmacy network. This means that
you can get your prescriptions easily and quickly. You can visit
and select Find a Pharmacy
under the Prescriptions tab to find a retail pharmacy near you. In addition, we are affiliated with
Pharmacy Advantage Home Delivery Service so that you can refill or renew your prescriptions for a
90-day supply safely and securely online. Prescriptions are delivered in seven to 10 working days by
first-class mail. Allow enough time for mailing so that you won’t run out of your medicine. For more
details, visit or call
(800) 456-2112
Prescription Benefit
With a prescription drug rider, you will have prescription coverage. You can search for your medication on
the formulary. A formulary is a list of covered prescription drugs. Prescription drugs are self-administered
drugs that you can obtain from pharmacies. The list of covered prescription drugs is selected in consultation
with a team of health care providers and represents the prescription therapies believed to be a necessary
part of a quality treatment program. Your health plan will cover the drug listed in the formulary as long as
the drug is medically necessary, the prescription is filled at a plan network pharmacy and other plan rules
are followed. You may view the formulary at
We review new medications on an ongoing basis. We may add or remove items to or from our
formulary during the year. This information is also online at
In addition to prescription drugs, our formulary also includes medical drugs. Medical drugs are drugs
that are supplied by your health care provider and given to you in your doctor’s office or health care
facility. Drugs provided for home infusion therapy are also considered medical. Please refer to your
plan document for information about your cost sharing for medical drugs.
Some covered drugs may have additional requirements or limits on coverage.
These are listed on the formulary and may include:
Prior Authorization –
Some medications on the formulary have criteria you must meet before they are
covered. This means that you will need to get approval before you fill your prescriptions for these drugs.
You may also receive coverage for a medication not included on our formulary or ask us to exempt you
from a formulary requirement through the exception process. Your doctor must submit a request
indicating why formulary requirements should not apply. Your doctor may use the forms available at
to send us information when requesting either prior authorization or an exception.
Step Therapy –
In some cases, your health plan requires you to first try certain drugs to treat your
medical condition before coverage of another drug for that condition. For example, if Drug A and Drug
B both treat your medical condition, your health plan may not cover Drug B unless you try Drug A first.
If Drug A does not work for you, Drug B will then be covered.
Quantity Limits –
Certain drugs have quantity limits. A quantity limit is the maximum quantity that
can be dispensed for each fill of medication or the maximum number of fills allowed for treatment of
certain conditions. Specialty drugs and injectable drugs (except insulin) are limited to a maximum
30-day supply per fill and are available through a specialty pharmacy. Some specialty drugs require a
15-day fill first.
Generic Drugs –
When an FDA-approved generic drug is available, your prescription will be filled with
the generic form of the medication. Generic drugs contain the same active ingredients and are
equivalent in strength and dosage to the original brand-name product. They also cost you and your
plan less money than a brand-name drug.