Prescription 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.

Some covered drugs have requirements or limits. These requirements are listed on the drug list and may include:

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: Generic – Non-brand name drugs with the lowest copay.
• Tier 2: Preferred brand – Brand name drugs with the lowest copay.
• Tier 3: Non-preferred brand – Brand name drugs with a higher copay.
• Tier 4: Specialty drugs – Biologics or prescription drugs, including biosimilar and generic drugs approved by the FDA, used to treat complex or chronic illnesses and require special handling, provider coordination and patient education for safe and effective use. These are designated by us to be a specialty drug.
• 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.

Medical drugs and mail order

Medical drugs

These drugs can be dispensed by a home infusion pharmacy for infusion in the home, and coinsurance may apply.

Mail-order service and specialty provider service

HAP offers mail-order 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.