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Utilization management

Learn if your drugs have coverage restrictions or limits

HAP HMO, HMO-POS, PPO and D-SNP plans have additional requirements for coverage or limits on coverage for certain prescription drugs. A team of doctors and pharmacists developed these requirements and limits to help us provide quality care and control drug plan costs.

Find out if a drug you take is subject to these additional requirements or limits by searching for your medication in our 2024 Medicare formulary, also known as a drug list. To search drug list press Ctrl+F (Command+F for Mac) and type in the name of the drug to see whether it’s included in the covered drug list for your type of plan. The drug name will be highlighted.

If your drug has additional restrictions or limits, you can ask us to make an exception to our coverage rules.

part d medicare video image
Medicare Part D explained
Medicare prescription drug coverage options in a nutshell. (Video, 3:43)
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Prior authorization

We require you get approval from us before you fill certain prescriptions. This gives us a chance to be certain these drugs are used correctly and only when truly necessary. If you don’t get prior authorization, we may not cover the drug.

Learn more about prior authorization criteria (2024)

Part B versus Part D prior authorization

Some prescription drugs require prior authorization to determine whether they should be covered under Medicare Part B or Part D. These drugs may be covered under either part depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug in order for us to determine how to cover it. Drugs requiring this review have a B/D next to them on the drug list.

Quantity limits

We limit the amounts of certain drugs we’ll cover per prescription over a defined period of time.

Step therapy

In some cases, we require you to first try one drug 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, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, we will then cover Drug B.

Learn more about step therapy for Part D drugs (2024)

Generic substitution

If there is a generic version of a brand-name drug available, our pharmacies will automatically give you the generic version. If your condition requires you must take the brand-name drug, your doctor must submit a prior authorization request.

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Health Alliance Plan (HAP) has HMO, HMO-POS, PPO plans with Medicare contracts. HAP Medicare Complete Duals (HMO D-SNP) is a Medicare health plan with a Medicare contract and a contract with the Michigan Medicaid Program. Enrollment depends on contract renewals.