AlohaCare covers certain prescription drugs for our QUEST Integration members.
The formulary is a list of the drugs that we cover. Generally, we will cover the drugs listed on our formulary as long as the drug is medically necessary and the prescription is filled at a network pharmacy. See below for information on restrictions and limitations. We may add or remove drugs from our formulary during the year. We will provide updates when the formulary changes.
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. The formulary will tell you about:
- The drugs included in our formulary
- Quantity limits for drugs
- Restrictions that apply to drugs such as prior authorization requirements
- How to obtain prior authorization for a drug, if required
- How your physician may request an exception to our formulary, including the documentation that we require to review this request
- How you or your physician may appeal our decision not to approve the request for an exception
- The Process of generic substitution of drugs
- Step therapy requirements
- Therapeutic interchange requirements
- Any other requirements, restrictions, limitations, or incentives that apply to the use of certain drugs
There is little difference between a brand name drug and the generic version. Generic drugs have the same ingredients as brand name drugs. They are usually a different color and shape. Generic drugs are not as expensive as brand name drugs. Your pharmacy will fill your prescription with a generic drug if it is available. Generic medications are as safe and effective as their brand name drugs.
AlohaCare has a committee of physicians and pharmacists that decide about our medication procedures. They review the available drugs and select the ones that they believe are the best for our members.
Most of the time, you will get a 30 day supply unless your doctor orders a supply for a shorter period of time, based on your need for the drug (for example, antibiotics). Some covered drugs may have additional requirements or limits on coverage. These limitations are marked next to each drug on the formulary with "LA," "PA," "QL" or "ST." Situations in which a drug limit may apply include:
- Limited Access (LA): This prescription may be available only at certain pharmacies. For more information, please call AlohaCare Member Services.
- Prior Authorization (PA): AlohaCare QI requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you do not get approval, we may not cover the drug.
- Quantity Limit (QL): For certain drugs, AlohaCare QI limits the amount of the drug that we will cover.
- Step Therapy (ST): In some cases, AlohaCare QI requires you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.
Generic substitution or therapeutic interchange may also apply. You may be asked to take a drug that is chemically identical (not brand name) or chemically different from the drug originally prescribed. This substitution or change will have the same therapeutic purpose and will be used for the same FDA approved conditions. The pharmacist or prescriber may ask you to take this drug and will explain the reasons why he or she believes this is a better drug choice for you. You do not have to agree. If you do not agree, you or your physician may request a prior authorization (PA).
There is no copayment for our drugs, unless you have Medicare. If you have Medicare, your Medicare Part D plan will cover most of your drugs though you will have a copayment. There are certain drugs and over-the-counter medications not covered by your Medicare Part D plan that AlohaCare may cover without a copayment.
If your drug is not listed, contact your doctor. Your doctor may prescribe another drug that is similar to a drug on our drug list. Or, your doctor can ask for a prior authorization (PA) by calling the pharmacy department toll free at 877-973-7418.
You or your doctor can ask for a prior authorization (PA) by calling the pharmacy department toll free at 877-973-7418 to request a certain drug that is not on our list. We will ask your doctor for the reason why you are requesting a certain drug. We will let you and your doctor know if we approve your request.