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In some cases, it may be possible to receive an exception for nonformulary or nonpreferred formulary drugs. These are drugs not on our drug list (formulary) or are in a tier that is higher than you feel is appropriate.
If a drug your doctor prescribes isn’t on our drug list, or if the drug is subject to one of our utilization management requirements, such as step-therapy or quantity limits, you or your doctor can request a formulary exception.
A nonformulary drug we approve through the formulary exception process will be considered a nonpreferred generic (Tier 2) or non-preferred brand (Tier 4) drug.
In order for us to consider a request for a formulary exception, the prescribing physician must provide an oral or written supporting statement that the drug is medically necessary to treat your condition. The doctor may provide one or more of these reasons why you need an exception:
If your drug is in tiers 2, 3, or 4 and you believe it should be available in a lower tier, you or your doctor can request a tiering exception.
Please note that a tiering exception isn’t available for specialty (Tier 5) drugs.
You may not request a tiering exception for a nonformulary drug that we have approved through the formulary exception process.
In order for us to consider your request for a tiering exception, the prescribing physician must provide an oral or written supporting statement that the preferred (lower cost-sharing) drug(s) available for treatment of your condition would not be as effective as the requested drug and/or would have adverse effects for you.
To request an exception or prior authorization, use the Request for Medicare Prescription Drug Coverage Determination form (PDF).
The prescribing doctor must sign the completed form and send it, with appropriate documentation of medical necessity, to us at the address below:
Health Alliance Plan
Attn: Pharmacy Care Management
2850 W. Grand Blvd.
Detroit, MI 48202
Fax: (313) 664-8045
If approved, formulary exceptions will remain in effect until at least the end of the calendar year but may be approved up for to 12 months. Tiering exceptions will remain in effect until the end of the calendar year (so long as your doctor continues to prescribe the drug and it continues to be considered safe and effective).
If we deny your request, you have the right to request an appeal.
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2019 Health Alliance Plan of Michigan
Y0076_ALL 2020 HAP Website_M
CMS Accepted 9/29/2019
Last Updated 12/20/2019
Health Alliance Plan (HAP) has HMO, HMO-POS, PPO plans with Medicare contracts. HAP Empowered Duals (HMO SNP) is a Medicare health plan with a Medicare contract and a contract with the Michigan Medicaid Program. Enrollment depends on contract renewals.
This information is not a complete description of benefits. For more information call Medicare Michigan customer service at (800) 868-9885 (TTY: 711) 8 a.m. to 8 p.m., seven days a week (Oct. 1 – March 31) / 8 a.m. to 8 p.m., Monday through Friday (April 1 - Sept. 30).
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