CurrentCareSourcePolicy N/A

List of Covered Drugs (Drug List) — HAP CareSource MI Health Link

Defines the insurer's prescription and selected OTC/non-drug item coverage, tiering, restrictions (prior authorization, quantity limits, step therapy, mail-order, limited distribution), exception and transition rules, member cost-sharing (no copays), and how changes to the Drug List are communicated.

Policy Summary

PayerCareSource

PolicyList of Covered Drugs (Drug List) — HAP CareSource MI Health Link

Policy CodePolicy N/A

Change TypeClarified/update timestamps; formulary table updates (non-material)

Effective Date

Next Review Date

Key ActionProviders must request PA for drugs labeled 'PA' or 'B/D PA' before dispensing to ensure coverage; lack of PA may result in non-coverage/denial.

POLICY UPDATE CHANGES

Drug List was updated and last updated on 11/13/2025; document updated on 12/01/2025 header.

This part states 'This drug list was last updated on 11/13/2025.'

This excerpt includes repeated entries showing tier, PA, QL, MO/LA/NDS flags for multiple antineoplastic/immunosuppressant agents.

This drug list segment includes an update timestamp: 'This drug list was last updated on 11/13/2025' repeated in the text.

This segment notes that 'You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.' and repeats 'This drug list was last updated on 11/13/2025.'

Drug list last updated on 11/13/2025 (document contains repeated update footers).

Drug list last updated on 11/13/2025 (document indicates update date).

This part of the drug list shows updated entries and tier assignments for multiple antidotes and diagnostic/miscellaneous agents.

11/13/2025Drug list last updated

2Formulary Tiers

72hStandard exception decision time

30 daysStandard retail/mail supply limit (NDS)

someProducts with NDS / NDC rules

Coverage Summary

Coverage When Medically Necessary

HAP CareSource MI Health Link will cover drugs on the Drug List when ALL of the following are met:

ALL of the following

The drug is listed on the HAP CareSource MI Health Link Drug List (formulary).
Your prescriber (doctor or other authorized prescriber) states the drug is medically necessary to improve or maintain your health.
You obtain the drug from a HAP CareSource MI Health Link network pharmacy (a pharmacy with an agreement to provide services to plan members).
Network pharmacy requirement applies unless an exception or documented emergency/transition supply situation applies.
And when applicable, one of the following utilization management conditions is met:

Policy Summary

PayerCareSource

PolicyList of Covered Drugs (Drug List) — HAP CareSource MI Health Link

Policy CodePolicy N/A

Change TypeClarified/update timestamps; formulary table updates (non-material)

Effective Date

Next Review Date

Key ActionProviders must request PA for drugs labeled 'PA' or 'B/D PA' before dispensing to ensure coverage; lack of PA may result in non-coverage/denial.

On This Page

Drug List Changes and Transition Supplies

Formulary change, transition supply, and notice rules that apply when drugs or coverage rules change:

ALL of the following

For formulary changes that are not immediate safety or market-safety driven, HAP CareSource MI Health Link will provide at least 30 days' advance notice before making the change; notices will be mailed and posted online.
When a covered drug is replaced by a new generic or certain biosimilar versions, changes may occur immediately; members and providers will be notified after the change is made.
Members affected by formulary changes may request a 30‑day transition supply if the drug will no longer be covered or if coverage rules will change, to allow time to consult with prescriber or seek an exception.
Member or prescriber must request the refill/transition supply; plan will allow a 30-day supply after request when advance notice is given.
If a drug is removed immediately due to safety concerns, FDA action, or market withdrawal, members will be notified after the change and should contact their prescriber for alternatives.
Exceptions to formulary changes may be requested by the member or provider; the plan will provide a notice with steps to request an exception and timelines for decisions.

New Member / Transition and Emergency Supply

Temporary coverage, emergency supplies, long‑term care (LTC) transition rules, and related member protections:

ALL of the following

New members or members transitioning between plans may receive temporary coverage of current medications to avoid interruption in therapy; the plan provides transition fills as described on the Drug List and in member materials.
For members newly enrolled and taking a non‑formulary drug, a temporary or emergency supply may be provided to allow time to transition to a formulary alternative or to request an exception.
Member should contact Member Services or their Care Coordinator; prescriber may request a PA or exception to continue therapy.
Long‑term care (LTC) residents transitioning into the plan are eligible for transition supplies per state and Medicare rules to prevent therapy interruption; prescribers in LTC settings should coordinate with the plan for ongoing coverage or PA requirements.
Emergency supplies: pharmacies may dispense emergency supplies in accordance with network and state rules; members should follow up with prescriber and plan for continued coverage or PA.
All transition, emergency, and LTC transition supplies remain subject to utilization management flags and coverage restrictions listed on the Drug List; extensions beyond the transition supply require approved PA or exception where applicable.

Applicable Codes and Abbreviations

Plan action / table codesmixed

PA	Prior Authorization required before coverage
QL	Quantity Limit — maximum allowed quantity per time period
MO	Month supply limit or month-based limitation
NDS	Non-Preferred Drug/Substitution — clinical or formulary substitution guidance
B/D PA	Brand/Dispense Prior Authorization — PA specifically for brand or dispense-as-written requests
ADD	Additional documentation required — prescriber must supply extra clinical information or forms
LA	Limited Access — restricted distribution or specialty channel required
ST	Step Therapy — trial of preferred agent(s) required prior to coverage
V	Vaccine-specific administration or coverage indicator

Preferred NDC prefix referencesNDC

Preferred NDC prefix list	Certain biologics and specialty products use preferred NDC prefixes (e.g., 00074 for specified HUMIRA products). Refer to online Drug List for full prefix mappings; pharmacies should use preferred NDCs when submitting claims to ensure proper billing and dispensing.
NDCS STARTING WITH 00074	Preferred NDCs for specified HUMIRA products and related pen presentations

NDC prefix-specific inhaler restrictionNDC

NDC-prefix inhaler restriction

Some inhaler products are restricted by NDC prefix; claims submitted using non-preferred NDC prefixes may trigger coverage review or prior authorization. See online formulary for prefix-specific rules and exceptions.

Example Drug Table Entries (representative formulary lines)mixed

ADD	Additional documentation required for selected specialty and oncology agents (see policy list below).
BARACLUDE ORAL SOLUTION	Entecavir oral solution — PA may be required for certain indications; check quantity limits.
BIKTARVY	Antiretroviral single-tablet regimen — PA and specialty pharmacy distribution may apply.
CABENUVA	Long-acting injectable cabotegravir/rilpivirine — LA and PA required; administered in clinical setting.
cidofovir	Antiviral intravenous — billed under medical/rule-based coverage; PA and documentation required.
CRESEMBA ORAL	Isavuconazole oral — may require PA for systemic fungal infections; check IV/oral interchange rules.
amphotericin b	Multiple formulations (conventional and lipid) — IV formulations require medical benefit billing and PA in some cases.
fluconazole (IV piggyback 200 mg/100 ml & 400 mg/200 ml)	IV piggyback concentrations listed — medical benefit; quantity and concentration-specific codes may apply.
COMETRIQ ORAL CAPSULE 140 MG/DAY (80 MG)	Cabozantinib dosing example — PA and monitoring required.
COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY)	Alternate dosing listed — PA and dosing documentation required.

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List of Covered Drugs (Drug List) — HAP CareSource MI Health Link

Coverage Summary

Prior Authorization, Quantity Limits, Step Therapy

Initial Therapy Criteria

Continuation Therapy Criteria

Applicable Codes and Abbreviations

Provider Actions & Operational Requirements

Background

Revision History