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Utilization management

Learn if your drugs have coverage restrictions or limits

HAP Senior Plus® 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 2018 drug list (PDF). 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.

2017 drug list (PDF)

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

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 2017 prior authorization criteria (PDF).
2018 prior authorization criteria (PDF)

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.

Learn more about 2017 Part B versus Part D prior authorization criteria (PDF).
2018 Part B versus Part D prior authorization criteria (PDF)

Quantity limits

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

Learn more about 2017 quantity limits (PDF).
2018 quantity limits (PDF)

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 2017 step therapy (PDF).
2018 step therapy (PDF)

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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Copyright © 2017 HAP
2017 Health Alliance Plan of Michigan
Y0076_ALL 2018067 2018 WEB 10.1
CMS Approved: 10/24/2017
Last Update 10/1/2017

HAP Senior Plus HMO, HMO-POS, and PPO are health plans with a Medicare contract. Enrollment in these plans depends on contract renewal. HAP Senior Plus PPO is a product of Alliance Health and Life Insurance Company, a wholly owned subsidiary of HAP. Alliance Medicare Supplement is a product of Alliance Health and Life Insurance Company, a wholly owned subsidiary of HAP.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

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  • HAP Medicare Sales:

    (877) 547-5186 (TTY:711)

  • (800) 868-3153 TTY: 711

    HAP Senior Plus®

    (800) 801-1770 TTY: 711

  • HAP Senior Plus®(PPO)

    (888) 658-2536 TTY: 711

  • Alliance Medicare Supplement:

    (800) 873-7526 TTY: 711