Pharmacy

Before providing care or prescribing medicine for your patients, please review the HAP CareSource™ MI Coordinated Health (HMO D-SNP) Formulary and the Formulary Changes.

Formulary

Use the Formulary Search Tool to look up covered drugs and criteria. HAP CareSource MI Coordinated Health updates the Formulary (coming soon) regularly. Visit the Drug Formulary page for more information.

Copayments

Members who have HAP CareSource MI Coordinated Health coverage for both Medicare and Medicaid have no copays for covered prescription and over the counter (OTC) drugs.

Formulary Exceptions

During the course of a member’s medical care, there may be instances when a member requires a non-formulary drug or a drug that has formulary limits or restrictions (e.g., step therapy requirements, prior authorization or quantity limits).

We may approve an exception request for a non-formulary drug or a drug that has formulary limits or restrictions when medically necessary. To determine medical necessity, we will verify, through the provider’s supporting statement(s) and/or standards documented in clinical guidelines adopted by HAP CareSource MI Coordinated Health, that:

  • The member has tried and failed and/or has documented contraindications or intolerance to the equivalent formulary medications, and
  • No other formulary agent is appropriate to treat the member’s condition.

Exception requests will be processed through HAP CareSource MI Coordinated Health Pharmacy Benefit Manager (PBM) prior authorization review process.

Tiered Medications

All medications are in one tier, including generic drugs, brand name drugs, and Medicaid-covered drugs and over-the-counter (OTC) drugs.

Prior Authorization Review Process

HAP CareSource MI Coordinated Health will process coverage determinations and exception requests in accordance with Medicare Part D regulations and according to Medicaid requirements, when applicable. Requests will be handled through the prior authorization review process. Prior authorization requires a drug to be “pre-approved” for it to be covered under a benefit plan.

The prior authorization staff will adhere to the Centers for Medicare & Medicaid Services (CMS) approved criteria, for Medicare Part D drugs and to the Michigan Medicaid Fee-for-Service (FFS) criteria when applicable.

Providers can submit requests by any of the methods identified below. Providers are required to submit pertinent medical/drug history, prior treatment history and any other necessary supporting clinical information with the request. Standard requests will be reviewed, and determinations will be made within 72 hours.

Expedited or urgent requests will be reviewed, and determinations will be made in 24 hours. A request is considered urgent if the requester believes that applying the standard process may seriously jeopardize the member’s life, health or ability to regain maximum function. Providers will be notified by phone or fax of the determination.

Prescribers or their designated agents may request prior authorization for HAP CareSource MI Coordinated Health members through our pharmacy benefit manager (Express Scripts/Evernorth Coverage Review Department).

Pharmacy drugs (self-administered)

Medical drugs (physician administered)

For more information, please call Provider Services at 1-833-230-2159.