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Prescription Drug Coverage

What’s covered and how to use your benefits

Our drug list, also known as a formulary, contains a detailed overview of the drugs we cover, along with the copay amount for each.

Use our drug finder tool to search for drugs that HAP covers. Some covered drugs may have requirements or limits. These are displayed in our drug finder tool, when you search for the drug

Prior authorization

You or your doctor must get approval from HAP before your prescription is filled.

Step therapy

In some cases, HAP may require you to first try a certain drug to treat your condition before another drug is covered.

Quantity limits

A limit on the amount of medication you can receive.

Specialty pharmacy

Prescriptions must be filled through our partner, Pharmacy Advantage.

The out-of-pocket costs for drugs are defined by tiers. For qualified health plans, they are:

  • Tier 1 drugs (Select Generic Drugs) - FDA approved drugs that contain the same active ingredient(s), identical in concentration and strength to their brand name drug. Drugs in this tier are comprised of low-cost generic drugs.
  • Tier 2 drugs (Generic and Select Brand Drugs):  - FDA approved generic and brand name drugs that meet rigorous quality, safety and cost-effectiveness guidelines, with a slightly higher out of pocket cost than Select Generic Drugs.
  • Tier 3 drugs (Preferred Brand):  - FDA approved brand name drugs that meet rigorous quality, safety and cost-effectiveness guidelines.
  • Tier 4 drugs (Non-preferred Brand and Generic Drugs) - FDA approved generic and brand name drugs that meet rigorous quality, safety and cost-effectiveness guidelines that are considered non-preferred by us, which may also include higher cost generics.
  • Tier 5 drugs (Preferred Specialty Drugs) - Brand, generic or biosimilar drugs approved by the FDA that are used to treat complex and/or chronic illnesses and required close supervision and monitoring. The drugs in this category include higher-cost injectable/infusible and certain orally inhaled drugs that may require prior authorization. To assure safe and quality care; these drugs must be obtained by a designated/contracted specialty pharmacy.
  • Tier 6 drugs (Non-Preferred Specialty Drugs) - Brand, generic or biosimilar drugs approved by the FDA that are used to treat complex and/or chronic illnesses and required close supervision and monitoring. The drugs in this category include higher-cost injectable/infusible and certain orally inhaled drugs that may require prior authorization. To assure safe and quality care; these drugs must be obtained by a designated/contracted specialty pharmacy.
  • Preventive: Generic preventive prescription drugs - used to prevent illnesses, diseases or other health problems — that the Affordable Care Act requires us to cover without charging you a copay or other out-of-pocket costs.
  • Medical drugs - drugs infused or administered in a doctor’s office or facility that are covered under your medical benefit. Some medical drugs are classified as specialty drugs, and we may require that they are obtained from a specialty pharmacy and co-insurance may apply. Home Infusion drugs are obtained from Home Infusion pharmacies. These are considered medical drugs and coinsurance may apply.

Home delivery service and specialty provider service

HAP offers home delivery and specialty pharmacy services through Pharmacy Advantage, our contracted mail order provider. You can get up to a 90-day supply of some medications (new prescriptions or a simple refill). This saves time and money and eliminates trips to the pharmacy.