General coverage / member eligibility

This Drug List covers medications and certain OTC products available to HAP CareSource MI Coordinated Health members. Covered drugs must be medically necessary, prescribed by a licensed provider, and dispensed at a HAP CareSource network pharmacy. The plan follows Medicare and Michigan Medicaid rules; some products may have special pharmacy network, quantity, prior authorization, step therapy, or other utilization controls. Changes to the Drug List (adds/removals or rule changes) follow federal/state requirements and members may request exceptions or transition supplies when rules change.

Drug List change exceptions / transition supplies

Transition supplies, formulary change exceptions, and appeals (exceptions) are available to members under Medicare and Medicaid rules. The following criteria groups describe how members and providers can obtain transition supplies, request a formulary exception, and the utilization controls applied per drug.

Exception (appeal) requests

Members and prescribers may request an exception (also called an appeal) when coverage is denied or a drug is subject to utilization controls. The plan processes exceptions per regulatory timelines and offers expedited reviews when delay would risk health.

Utilization Controls by Drug (per-line entries)

Utilization controls are applied at the drug or formulation level and may include prior authorization, quantity limits, step therapy, age or diagnosis restrictions, refill timing, or specialty pharmacy requirements. The plan enforces these per-line (per product/NDC/formulation) rules as listed on the Drug List.

Per-drug utilization management requirements (listed per product)

Per-drug utilization management requirements (examples summarized; see the Drug List for each product's specific rules). Each listed product entry includes formulary tier, coverage status, and any of the above utilization controls.

Formulary entry controls

Formulary entry controls govern how drugs are placed on the Drug List and what utilization restrictions apply when they are listed. Controls include tiering, PA, step edits, quantity limits, and specialty designation.

Formulary entries and utilization controls

Formulary listings include specific utilization controls for each drug/formulation. The Drug List indicates coverage actions (covered, not covered, PA required, quantity limit, step therapy) and any restrictions by formulation or route.

Formulary listing usage rules (implicit)

Usage rules and coverage restrictions are applied as implicit policy logic across the Drug List: prescribers must follow documented PA and step therapy processes; pharmacies must adjudicate claims per listed quantity and refill rules.

Coverage actions/limits included in list

The Drug List includes numerous coverage actions and limits. Examples of coverage actions applied to listed drugs include denial for lack of PA, approval with a specified quantity limit, or coverage contingent on step therapy completion.

Coverage / Restrictions entries (per listed drug/formulation)

Individual Drug/Formulation coverage and restrictions are listed on the Drug List pages. Each entry includes product name, formulation, coverage status, and any utilization controls or restrictions applicable to that product.