Pharmacy

Prescription coverage

Your HAP CareSource plan covers drugs. There are no copays for covered drugs. You must use a pharmacy in the network to fill your prescriptions. You can find a pharmacy near you by searching our website. Click on Find a Doctor/Provider at the top of this page to search for a doctor or pharmacy.

We cover drugs on a list called the preferred drug list (PDL), also called a formulary. The HAP CareSource PDL includes drugs on the Michigan Medicaid Managed Care Preferred Drug List and Common Formulary which are lists of drugs that all Michigan Medicaid health plans must cover. If you want to look at the drugs on the formulary, or search for a certain drug, you can search the list. It includes drugs from a pharmacy, not drugs from your doctor’s office or the hospital. The list includes prescription drugs and covered over-the-counter drugs. We also cover all drugs to help you stop smoking (e.g., nicotine gum, patches, lozenges, inhaler, Bupropion, Varenicline). You can search the list by brand name or generic name.

HAP CareSource works with the state and other health plans to develop and update the list. We update it at least four times a year. We add new drugs and sometimes change the status of some drugs. When we make a change, we update the website so it’s available for you, providers and our Member Services team. If we make a change to the drug list that affects you, we’ll send a letter to you and your doctor. This gives you time to talk to your doctor about the change.

Prescription coverage information

Formulary list and restrictions

We cover up to a one-month supply for most medications, or less, if your doctor prescribes less. We cover a three-month supply for many drugs that are taken every day. This includes drugs to treat diabetes, asthma, high blood pressure and other conditions. We cover up to a twelve month supply of birth control pills, contraceptive patches and the vaginal ring. For safety reasons, you must use a certain amount of your medication before you can fill it again.

We cover both brand and generics. Sometimes, we only cover the brand. Other times, we cover the generic. Your pharmacy will give you the drug that’s covered.

Some drugs need approval before we’ll cover them. Prior authorization may be required when:

    • A drug has step therapy, which means you must try certain drugs before another drug is covered.
    • We need certain medical information from your doctor to make sure the drug is appropriate for treatment. For example, we might need diagnosis information, lab test results and history of medications.
    • A drug is on the list but there are other drugs that are preferred. 
    • When the generic drug is covered, but the brand name drug is needed instead for a medical reason. For example, you’re allergic to a certain dye/color in the medication. These situations are rare.

Some drugs have age restrictions or quantity limits. These are usually based on safety.

All drugs on the list are covered. If you need a drug that’s not on the list, or there isn’t a good alternative on the list, you or your doctor can ask for an exception to the formulary. You can also ask us to waive restrictions or limits on a drug. You can request an exception at the website, or by telephone through Member Services at 1-833-230-2053 (TTY: 711). Your doctor can send us an Exception Request form via fax or call us at 1-833-230-2102 (TTY: 711).

We also cover drugs that are given at your doctor’s office or in a facility. They are called medical drugs. Some medical drugs may also require approval. You can learn more about these drugs on the HAP CareSource Medicaid Medical Drug Review Guidelines.

We work with your doctor for the information we need for prior authorization or exception requests. Your doctor will tell us why the drug is necessary.

If we deny a drug request, we’ll send a letter to you and your doctor. The letter will tell you the reason why we denied the request. You have the right to appeal. If you want to appeal, you have 60 days from the date on the letter to appeal.

To learn more, visit our How and When to File an Appeal page.

Transition of Care Policy

Are you new to Medicaid or HAP CareSource? We want to make sure you get the drugs you need. 

Are you taking a drug that’s not on the drug list, that has restrictions or requires approval? We’ll cover a temporary supply to make sure you get the care you need. This temporary supply is for drugs that you’ve already been taking.

  • For most drugs, this will happen automatically at the pharmacy the first time you fill your drug with your new HAP CareSource card. 
  • For some drugs, we’ll give a transition supply if you, your representative, or your doctor asks. This includes drugs for pain, weight loss, drugs that need special monitoring, and others.
  • The following people can ask for a temporary supply:
    • You
    • Your doctor
    • Someone who has your permission to care for you
  • You can request the supply by:
    • Calling Member Services or your Care Manager.
    • Asking in writing by sending a letter to HAP CareSource.
  • You can get this temporary supply for the first 90 days when you are new to HAP CareSource. This is for drugs that you’ve already been taking. You can get your temporary 30-day supply within the first 3 months (90 days) of joining HAP CareSource. We call this a “transition” fill. After the drug is filled at the pharmacy, we’ll send a letter to you and your doctor. The letter has instructions about the temporary fill and what to do next.
  • We’ll work with your doctor to use a drug on the list or to approve your drug if there’s not a drug on the list is not that’s right for you. 
  • Benefit limitations

Some drugs are covered by the state of Michigan, not HAP CareSource. When you go to the pharmacy, you should always take your HAP CareSource card and your mihealth Medicaid card. Your pharmacy knows about these drugs and will bill the state for these drugs.

There are some drugs not covered by HAP CareSource or mihealth Medicaid, including:

  • Drugs not approved by the Food and Drug Administration
  • Drugs for cosmetic use
  • Experimental or investigational drugs
  • Combination cough/cold medications
  • Fertility drugs
  • Lifestyle drugs
  • Sexual or erectile dysfunction drugs
  • Replacement of lost or stolen medication
  • Any drug excluded for coverage by the state of Michigan

Here’s some information available once you sign on securely at MyCareSource.com.

  • Find your cost for a drug based on your Medicaid benefit (you pay zero)
  • Find a pharmacy in the network
  • Find a pharmacy near you by using a zip code
  • Check to see if your drug has a generic and if it’s on the list

You can also get this information by calling Member Services at 1-833-230-2053 (TTY: 711). You can reach us 24 hours a day, seven days a week.

Specialty drugs

Specialty drugs are prescription drugs that need special handling, coordination with your doctor and patient education for safe and effective use.

One specialty pharmacy we work with is Pharmacy Advantage. Pharmacy Advantage can send your prescriptions to you by mail. You can also use any other pharmacy in the network if you prefer. These drugs may require prior authorization, meaning your doctor has to ask for permission for them to be covered by your plan.

Conditions that may require treatment with specialty medications include:

  • Crohn’s disease
  • Hemophilia
  • Hepatitis B
  • Hepatitis C
  • Immune disorders, such as Guillain-Barré syndrome or lupus
  • Kawasaki disease
  • Multiple sclerosis
  • Plaque psoriasis
  • Rheumatoid arthritis
  • Respiratory syncytial virus (RSV) (prevention)

Pharmacy Advantage Specialty Program

This program focuses on safe use of drugs. We want to make sure you know how to take them safely and correctly. Here are some of the services from Pharmacy Advantage:  

  • We may call you or provide helpful booklets or information
  • We’ll make sure you know how to use your medication
  • We can remind you about refills and how to take your medication
  • Nursing and social support to work with your doctor
  • Free supplies as needed for your medications and your condition (e.g., syringes)
  • We will check to confirm your coverage

Sign up for Pharmacy Advantage.

Formulary and forms

Formulary

Forms

Non-Opioid Directive Form

With this form, you can tell your health care providers when you do not want to get opioids. This form was created by the state of Michigan. You (or legal guardians) who want to use this directive can download and fill out the form. Give a copy to your health care providers, including dental providers.