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Prescription Benefit
You have prescription coverage if you have a prescription drug rider with HAP. You can search for your
medication on our 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. We will cover the drug listed in our
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
hap.org/prescriptions/lists.php
.
We review new medications on an ongoing basis. We may add or remove items from our formulary
during the year. This information is also online at
www.hap.org/prescriptions/index.php
. 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 Summary of Benefits and Coverage (SBC) 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 our formulary have criteria you must meet before we cover
them. This means that you will need to get approval from HAP before you fill your prescriptions for these
drugs. You may also ask us to cover 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 to us
indicating why formulary requirements should not apply. Your doctor may use the forms available at
hap.org/mrf
to send us information when requesting either prior authorization or an exception.
Step Therapy:
In some cases, HAP requires you to first try certain drugs to treat your medical
condition before we will cover another drug for that condition. For example, if Drug A and Drug B both
treat your medical condition, HAP may not cover Drug B unless you try Drug A first. If Drug A does not
work for you, we will then cover Drug B.
Quantity Limits:
Certain drugs have quantity limits. A quantity limit is the maximum quantity that
can be dispensed per 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. Generic drugs cost you and
your plan less money than a brand-name drug.