Pharmacy

Before providing care or prescribing medicine for your patients, please review the HAP CareSource™ MI Health Link (Medicare-Medicaid Plan) Formulary and the Formulary Changes. 

To make your search easy, use the Formulary Search Tool to look up covered drugs and criteria.

Formulary or Drug Formulary

HAP CareSource MI Health Link updates the Formulary regularly. Visit the Drug Formulary page for more information.

Copayments

Members who have HAP CareSource MI Health Link 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).

HAP CareSource MI Health Link 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, HAP CareSource MI Health Link will verify, through the provider’s supporting statement(s) and/or standards documented in clinical guidelines adopted by HAP CareSource MI Health Link, that:

  • The member has tried and failed and/or has documented contradictions 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 Health Link’s Pharmacy Benefit Manager (PBM) prior authorization review process.

Tiered Medications

Medications are classified using the following tier levels:

  • Tier 1: Generic Drugs
  • Tier 2: Brand Drugs

Members do not pay for any covered drugs.

Prior Authorization Review Process

HAP CareSource MI Health Link will process coverage determinations and exception requests in accordance with Medicare Part D regulations. 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 HAP CareSource MI Health Link’s Centers for Medicare & Medicaid Services (CMS) approved criteria.

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 authorization from the ESI Coverage Review department by one of the following mechanisms:

  • Written request via fax: 1-800-716-3231 for oral medications and injectable/specialty medications
  • Toll-free phone number: 1-800-935-6103

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