Pharmacy Information
At HAP Midwest Health Plan, we care about our members and those who provide service to our members. We realize medication is an important part of health management. Because we care, we developed this guide to help our members get the medication they need to stay healthy and to assist our providers in prescribing effective medication management.

In order to streamline drug coverage policies for Medicaid and Healthy Michigan Plan members and providers, the Michigan Department of Health and Human Services (MDHHS) has created a formulary that is common across all contracted Medicaid Health Plans including HAP Midwest Health Plan for the current Comprehensive Health Plan Contract. As part of the Common Formulary, minimum requirements will be established for drug utilization management policies such as quantity limits, age and gender edits, prior authorization criteria and step therapies. The Common Formulary includes drugs that are covered as a pharmacy benefit. Medicaid Health Plans may be less restrictive, but not more restrictive, than the coverage parameters of the Common Formulary.

All HAP Midwest Health Plan Medicaid members are covered by pharmacy benefits. There are no co-payments or out-of-pocket costs for covered pharmacy benefits. The HAP Midwest Health Plan drug formulary applies to medications prescribed in an outpatient setting, not medications used during an inpatient admission while in the hospital. All prescription benefits are available at conveniently located pharmacies located in your community. Please refer to the Pharmacy Look Up tool to find a pharmacy convenient to you. HAP-Midwest Health Plan does not offer a mail order benefit. Inquire at your pharmacy of choice for delivery options if you cannot pick up your medications.

Whenever an FDA approved generic drug is available, prescriptions will be filled with the generic equivalent form of the medication. Members who request a brand name drug when a generic equivalent is available, and without prior authorization, will be responsible to pay for the brand name drug. Medicaid members do not have a co-payment for authorized prescriptions.

The standard Quantity Limit (QL) is a one-month supply of prescription drugs, up to a 30-day supply. In most cases, prescriptions must be written by a HAP Midwest Health Plan participating provider and filled at a participating pharmacy.

STEP THERAPY (ST) coverage requires that a trial of another drug be used before the medication is covered. The Pharmacy Benefits Manager (PBM) logs all prescribed medication and can track medications that qualify for Step-Therapy.

Some drugs are listed on the Medicaid formulary and are not covered unless specific clinical information is provided by the ordering prescriber. A PRIOR AUTHORIZATION (PA) request is required to determine if the drug can be approved. A PA is required when:
  • Step-therapy criteria has not been met but the provider requests to prescribe a medication that requires step-therapy
  • Brand-name medication is prescribed when a generic equivalent is available
  • Specific clinical information is required to determine if the medication requested is appropriate to treat your illness (this includes diagnosis, laboratory test results, and medical record notes of previous treatments)
A PA form can be obtained by clicking the “Prior Authorization Form”, located on this page. Fax the completed form, along with supporting clinical documentation to (248) 540-9811 or phone at (248) 540-6686.

FORMULARY EXCEPTION - HAP Midwest Health Plan recognizes that medications may be needed that are not included on the Formulary. In these instances the prescriber may request an Exception. Exceptions will only be considered in cases where medical necessity is the basis for the request and there is no acceptable alternative available on the HAP Midwest Health Plan Formulary.

Exceptions are made by completing the "Exception Request Form" found on this page and submitting it by FAX to HAP Midwest Health Plan at (248) 663-3776. HAP Midwest Health Plan will notify the prescriber within 14 calendar days of approval or denial.

OFF-LABEL USE - Generally, drugs are only approved for FDA approved indications, dosages, and routes of administration. As medicine is constantly evolving and new uses for medications are developed, the use of medications for new indications prior to FDA approval are possible. Please refer to the "STATEMENT ON CRITERIA FOR APPROVAL OF COVERAGE FOR OFF-LABEL USE OF DRUGS" for HAP Midwest Health Plan guidelines found on this page.
Benefit Limitations
The following are not covered by HAP Midwest Health Plan:
  • Drugs not approved by the FDA (for indication, dosage, or route of administration)
  • Drugs of labelers not participating in the State of Michigan Rebate Program
  • Drug products used strictly for cosmetic purposes
  • Drugs prescribed specifically for medical studies (experimental and investigational drugs)
  • Drugs used for weight gain or loss
  • Drugs used to promote fertility
  • Drugs used to treat gender identity conditions, such as hormone replacement
  • Drugs used to treat sexual or erectile dysfunction
  • Replacement of lost or stolen medication
  • All medications covered by the Medicaid Carve-Out (Medicaid and CSHCS plans, MIChild beneficiares are not included in the state Carve-Out program)
  • Any drug or therapeutic class of drugs that are expressly excluded for coverage by the state of Michigan
Denial Process
When a drug is denied, the member and provider will be notified, in writing, of the reason for the denial and HAP Midwest Health Plan's appeal process. An appeal must be filed within 90 days from the date on the denial notification letter.

An Expedited Appeal is available when the drug is determined to be medically necessary and withholding the medication could seriously jeopardize the life or health of the member, could jeopardize the member's ability to regain maximum function, or would subject the member to severe pain, not managed without the requested medication. A determination will be made within 72 hours of the appeal request. To request an appeal or for additional information, call the Customer Services Department at (800) 654-2200, seven days a week, 8 a.m. to 8 p.m. TTY/TDD users dial 711.
Disclaimer
This formulary, provided by HAP Midwest Health Plan, is solely for the purpose of convenience for its members and providers and is in no way intended to be a substitute for the knowledge, expertise, skill or judgment, within the scope of the provider, in their choice of medication management. HAP Midwest Health Plan assumes no responsibility for the actions or omissions of any provider based upon reliance, in whole or in part, on the information contained herein. It is recommend the provider consult the drug manufacturer, product literature or standard references for information that is more detailed.