Pharmacy

As a Qualified Health Plan in the Health Insurance Marketplace, HAP CareSource provides prescription drug coverage. This benefit provides coverage for prescriptions obtained from a retail pharmacy, mail-order pharmacy or specialty pharmacy; and those that are administered in the patient’s home, including drugs administered through a home health agency.

HAP CareSource uses evidence-based guidelines to ensure health care services and drugs meet the standards of excellent medical practice and are the lowest cost alternative for the member. These requirements ensure appropriate use of these drugs.

Cost Share

Members may be required to pay cost share for prescription drugs. Cost share amounts vary based on plan and medication. Preventive drugs are covered at no member cost share. View the Provider Manual for more information, or call us at 1-833-230-2101.

Drug Formulary

HAP CareSource updates the formulary regularly. Visit the Drug Formulary page for more information.

Generic or Biosimilar Substitution

A pharmacy will provide a generic or interchangeable biosimilar drug if available in place of a brand name drug or reference biologic. This is called generic or biosimilar substitution. Members and providers can expect the generic or biosimilar drug to produce the same effect and have the same safety profile as the brand name drug or reference biologic. If a brand name drug or reference biologic is requested when an equivalent generic or biosimilar drug is available, you may need to request a prior authorization. Also, members may pay additional costs for brand name drugs or reference biologics when an equivalent generic or biosimilar is available.

For more information about generic substitution, please refer to the U.S. Food and Drug Administration (FDA) Orange Book. For more information about biosimilar substitution, please refer to the FDA Purple Book.

Prior Authorization, Step Therapy, and Quantity Limits

Utilization management may be applied to formulary drugs administered under the pharmacy benefit when they are included on the formulary. This could include:

  • Prior authorization – Requirement for additional clinical documentation prior to coverage of the requested drug
  • Step therapy – Requirement to try an alternate drug before the requested drug
  • Quantity limit – Limit on how much of a drug can be dispensed at a time or over a period of time

Refer to the Drug Formulary or Formulary Search Tool to determine which drugs are subject to these restrictions.

NOTE: Opioid drugs will always require prior authorization in the following circumstances:

  • The member has already had at least 90 days of therapy in the last 365 days,
  • The prescription is for more than 80 morphine milligram equivalents per day,
  • The member is receiving concurrent therapy with benzodiazepines, and/or
  • The prescription is for an extended-release opioid.

Drugs administered in an outpatient setting by a physician and billed under a member’s medical benefit may also require prior authorization. Refer to the Procedure Code Lookup Tool to determine which drugs require a prior authorization.

Please Note: Prior authorization requests may be submitted electronically via the HAP CareSource provider portal.

For all prior authorization decisions (standard or expedited), HAP CareSource provides notice to the provider and member as expeditiously as the member’s health condition requires. Please specify if you believe the request is urgent.

Policies and Criteria

HAP CareSource uses pharmacy policies or criteria when determining coverage of prescription drugs. Policies or criteria apply to coverage reviews for Non-Formulary drugs and drugs that are included on the Formulary with a Prior Authorization or Step Therapy requirement. These policies and criteria are a tool to be interpreted in conjunction with the member’s specific benefit plan and the Drug Formulary. Access pharmacy policies by selecting Policies from the Quick Links. Traditional drug review criteria can be viewed in the online Formulary Search Tool.

Non-Formulary Drugs and Therapeutic Interchange

HAP CareSource has an exception process that allows the member or the member’s representative to make a request for a formulary exception. Reasons for exceptions may include intolerance to drugs, allergies to formulary drugs, or inadequate/inappropriate response to formulary drugs. The member or member’s representative can call Member Services to make the request or complete the online Member Exception Request for Non-Formulary Medication (coming soon) The prescribing physician may also submit electronically via the the CoverMyMeds or SureScripts prior authorization portals.

When a non-formulary drug is requested due to drug allergy or intolerance or lack of efficacy of a formulary drug, the prescriber will need to submit supporting clinical documentation just like when requesting a prior authorization. Request for a non-formulary alternative is also called therapeutic interchange.

Home Infusion Therapy

HAP CareSource offers home infusion services to members who require treatment with certain injectable drugs. These services allow members to schedule and receive therapy safely and effectively in the comfort of their own home at a time that works best for their schedule. An infusion-trained nurse will administer the drug and remain with the member during the entire infusion. In most cases, home infusion services will be a lower cost to members through their plan benefits. Members can contact Member Services for more information about transitioning to home infusion therapy.

Maximum Allowable Cost (MAC)

HAP CareSource is dedicated to providing the most current MAC pricing for drug reimbursement.

MAC pricing can be accessed through the secure ESI Provider Portal.

MAC Appeals can be completed through the portal and by following the ESI Appeals Process instructions.

Pharmaceutical Management Procedures

To learn more about how to use our pharmaceutical management procedures, look in the drug formulary. HAP CareSource provides pharmaceutical management procedures annually and after updates. Changes are made in writing by mail, fax or email or via the web. If you have any questions regarding our pharmaceutical management procedures, please call Clinical Pharmacy Services at 1-833-230-2101.

Drug Safety Recalls

Sometimes, a drug manufacturer or the federal government issues drug recalls. To find out if a drug you have prescribed to a patient is being recalled, please check the listings on the FDA website.