Please click on the questions below to receive more
information on how AlohaCare Advantage's drug coverage works.
What is the AlohaCare Advantage
Formulary?
What are
generic drugs?
What
Pharmacies Can I Use?
Can the
Formulary change?
How do I
use the Formulary?
Are there any other restrictions
on coverage?
What if my drug is not on
the Formulary?
How do I request an exception
to the AlohaCare Advantage Formulary?
What if my request for
exception is not approved (denied)?
What if my
"Redetermination" request is not approved and I do not agree with the
decision?
What if I am traveling out of
state and I have to pay out of pocket for my medications?
What if I
have a complaint about the Prescription Drug Plan?
Who do I
call about the status of my appeal or coverage determination request?
Who do I contact if I have
questions about the grievance, coverage determination, exception or appeals
process?
Grievances
and appeals data
Transition policy for level of
care changes
Where
do I go for more information?
What is the AlohaCare Advantage Formulary?
A formulary is a list of drugs selected by AlohaCare
Advantage in consultation with a team of health care providers, which
represents the prescription therapies believed to be a necessary part of a
quality treatment program. AlohaCare Advantage will generally cover the drugs
listed in our formulary as long as the drug is medically necessary, the
prescription is filled at an AlohaCare Advantage network pharmacy, and other
plan rules are followed. For more information on how to fill your
prescriptions, formulary co-payments or drug tiering, please review your
Evidence of Coverage.
Our 2008/2009
Abridged Formulary is our partial formulary that includes only some of the
drugs covered by AlohaCare Advantage.
Our 2008/2009
Comprehensive Formulary is a complete listing of all prescription drugs covered
by AlohaCare Advantage
If you have any questions about our formulary you may
call our Customer Service Department at 973-6395 from Oahu or toll free at 1-866-973-6395
from the Neighbor
Islands or Mainland or
you can visit us Monday through Friday, 8 a.m. ? 5 p.m. TTY users should call
1-877-477-5990.
What are
generic drugs?
AlohaCare Advantage covers both brand-name drugs and
generic drugs. A generic drug has the same active-ingredient formula as the
brand name drug. Generic drugs usually cost less than brand name drugs and are
approved by the Food and Drug Administration (FDA). Generic drugs are
listed in lower-case italics (e.g., glipizide) within the formulary.
What
Pharmacies Can I Use?
You may use any of our network pharmacies. Our 2008/2009
Pharmacy Directory is updated every 3 months. If you have any
questions about whether a new pharmacy has been added, you may call our
Customer Service Department at 973-6395 from Oahu or toll free at
1-866-973-6395 from the Neighbor
Islands or Mainland or
you can visit us Monday through Friday, 8 a.m. ? 5 p.m. TTY users should call
1-877-477-5990.
Can the
Formulary change?
Yes, AlohaCare Advantage may add or remove drugs from
our formulary during the year. If we remove drugs from our formulary, or
add prior authorization, quantity limits and/or step therapy restrictions on a
drug or move a drug to a higher cost-sharing tier, we must notify members who
take the drug that it will be removed at least 60 days before the date that the
change becomes effective, or at the time the member requests a refill of the
drug, at which time the member will receive a 60-day supply of the
drug. If the Food and Drug Administration deems a drug on our formulary to
be unsafe or the drug's manufacturer removes the drug from the market, we will
immediately remove the drug from our formulary and provide notice to members
who take the drug.
Formulary Updates:
View
January Formulary Updates
View
February Formulary Updates
View
March Formulary Updates
View
April Formulary Updates
View
May Formulary Updates
View
June Formulary Updates
View
July Formulary Updates
View
August Formulary Updates
View
September Formulary Updates
View
October Formulary Updates
View
November Formulary Updates
How do
I use the Formulary?
Both the 2008/2009
Abridged Formulary and 2008/2009
Comprehensive Formulary contain additional information on how to use the
Formulary.
Are there any other restrictions on coverage?
Some covered drugs may have additional requirements
or limits on coverage. The limitations are marked next to each drug in the
Formulary with "PA", "QL" or "ST"
Prior Authorization (PA): AlohaCare Advantage requires you to get prior
authorization for certain drugs. You may need prior authorization for drugs
that are on the formulary or drugs that are not on the formulary and
were approved for coverage through our exceptions process. This means that you
will need to get approval from AlohaCare Advantage before you fill your prescriptions. If
you don't get approval, AlohaCare Advantage may not cover the drug.
Quantity
Limit (QL): For certain drugs,
AlohaCare Advantage limits the amount of the drug that AlohaCare Advantage will
cover. For example, AlohaCare Advantage provides 18 tablets per
prescription for Imitrex® 50 mg.
Step
Therapy (ST): In some cases,
AlohaCare Advantage requires you to first try certain drugs to treat your
medical condition before we will cover another drug for that condition. For
example, if Flonase® and Singulair® both treat your medical condition (e.g.,
allergic rhinitis), AlohaCare Advantage may not cover Singulair unless you try
Flonase first. If Flonase does not work for you, AlohaCare Advantage will then
cover Singulair.
You can ask AlohaCare Advantage for drug coverage
review to these restrictions or limits by completing our Request for
Medicare Prescription Drug Coverage Determination Form and faxing to
808-973-0726 or mailing to:
AlohaCare Advantage, Customer Service
1357 Kapiolani
Blvd. Suite 1250
Honolulu, HI 96814
What if my drug is not on the Formulary?
If your drug is not included in this formulary, you should
first contact Customer Service and ask if your drug is covered. You can
contact Customer Service Department at 973-6395 from Oahu or toll free at
1-866-973-6395 from the Neighbor
Islands or Mainland or
you can visit us Monday through Friday, 8 a.m. ? 5 p.m. TTY users should call
1-877-477-5990.
If you
learn that AlohaCare Advantage does not cover your drug, you have two options:
1. You can ask Customer Service for
a list of similar drugs that are covered by AlohaCare Advantage. When you
receive the list, show it to your doctor and ask him or her to prescribe a
similar drug that is covered by AlohaCare Advantage.
2. You can ask AlohaCare Advantage to
make an exception and cover your drug. See below for information about how
to request an exception.
How do I request an exception to the AlohaCare Advantage Formulary?
You,
your physician or your "Authorized Representative" can ask AlohaCare
Advantage to make an exception to our coverage rules.
1. You can ask us to
cover your drug even if it is not on our formulary.
2. You can ask us to
waive coverage restrictions or limits on your drug.
3. You can ask us to
provide a higher level of coverage for your drug. For example, if your
drug is usually considered a Tier 2 drug (BRAND), you can ask us to cover it as
a Tier 1 (GENERIC) drug instead.
You can
request an exception by completing Request for
Medicare Prescription Drug Coverage Determination Form and faxing to
808-973-0726 or mailing to:
AlohaCare Advantage, Customer Service
1357 Kapiolani
Blvd. Suite 1250
Honolulu, HI 96814
Someone you appoint can request an exception on your
behalf if you complete an Appointment of
Representative Form.
When requesting a formulary tiering or utilization
restriction exception, a statement from your physician supporting your request
should be submitted.
Generally, we must make our decision within 72 hours
of your request. If you or your physician believes that waiting 72 hours
for a standard decision could seriously harm your life or health or ability to
regain maximum function, you can ask for an expedited (fast) decision. With
your physician's support, we will give you a decision with 24 hours. Check
the box on page 2 of the Request for Medicare Prescription Drug Coverage
Determination form or have your physician call us at 866-973-6395 to request an
expedited decision.
What if my request for exception is not approved (denied)?
If your
first request for an exception is not approved, and you believe AlohaCare
Advantage did not have enough information to approve your exception, you may
submit additional information to AlohaCare. You can request a
redetermination and include the information that AlohaCare should
consider. You can request a redetermination by completing a Medicare Redetermination
Request Form and faxing to 808-973-0726 or mailing to:
AlohaCare Advantage, Customer Service
1357 Kapiolani
Blvd. Suite 1250
Honolulu, HI 968 14
What if my "Redetermination"
request is not approved and I do not agree with the decision?
You or your authorized representative may appeal this
decision by requesting an independent review of our decision to MAXIMUS.
MAXIMUS is the independent review organization contracted with the Centers for
Medicare & Medicaid Services (CMS), the government agency that runs the
Medicare Program. The independent review organization has no connection to
us.
You can use the Request for
Reconsideration of Medicare Prescription Drug Denial form or write directly
to:
MAXIMUS
Part D QIC
50 Square Drive
Victor, New York 14564
You can use an Appointment of
Representative Form to authorize someone to appeal on your
behalf. For other important information about your appeal rights, please
see your 2008/2009 Evidence of
Coverage.
What
if I am traveling out of state and I have to pay out of pocket for my
medications?
You need to save your
receipts and send them along with a completed ?Direct Claims form? to:
Medco Health Solutions, Inc.
P.O. Box 14718
Lexington, KY 40512
You can access the Direct
Claims by clicking the following link: Direct
Claims form.
What if I have a complaint about the Prescription Drug Plan?
A complaint is called a "grievance". If
you have a complaint about the drug plan that does not involve coverage or
payment, you have a right to file a grievance. You should file your
grievance within 60 days of the event that led to your complaint. Some
examples of why you might file a grievance include:
-
You believe the customer service hours should be different
-
You have to wait too long for your prescription
-
The pharmacy is charging you more than you think you should pay
-
The plan denies your request for an expedited (fast) coverage determination
To file a grievance, you may call our Customer
Service Department at 973-6395 from Oahu or toll free at 1-866-973-6395 from
the Neighbor Islands or Mainland or you can visit us
Monday through Friday, 8 a.m. ? 5 p.m. TTY users should call 1-877-477-5990.
You
may also contact us in writing at the following address:
Grievance and Appeals Department
AlohaCare
1357 Kapiolani Blvd, Suite 1250
Honolulu, HI 96814
FAX #: 808-973-0726
If you are concerned about the quality of care you
received, you may complain to us using the grievance process, to an independent
review organization called the Quality Improvement Organization (QIO), or to
both. Mountain - Pacific Health Foundation is the QIO for Hawaii. The independent
review organization has a contract with the Centers for Medicare & Medicaid
Services (CMS), the government agency that runs the Medicare program. The
independent review organization has no connection to us. If you choose to
submit a grievance to Mountain - Pacific Quality Health Foundation, you should
send it promptly to the following address:
Mountain - Pacific Health
Foundation
1360 S.
Beretania., Suite
501
Honolulu, HI 96814
Who do I call about the status of my appeal or coverage
determination request?
You may call our Customer Service Department at
973-6395 from Oahu or toll free at 1-866-973-6395 from the Neighbor Islands
or Mainland or you can visit us Monday through Friday, 8 a.m. ? 5 p.m. TTY
users should call 1-877-477-5990.You may write us at:
AlohaCare Advantage, Customer Service
1357 Kapiolani
Blvd. Suite 1250
Honolulu, HI 96814
Who do I contact if I have questions about the grievance, coverage
determination, exception or appeals process?
You may call our Customer Service Department at
973-6395 from Oahu or toll free at 1-866-973-6395 from the Neighbor Islands
or Mainland or you can visit us Monday through Friday, 8 a.m. ? 5 p.m. TTY users
should call 1-877-477-5990.You may write us at:
AlohaCare Advantage, Customer Service
1357 Kapiolani
Blvd. Suite 1250
Honolulu, HI 96814
You may also refer to your AlohaCare Advantage
Evidence of Coverage 2008/2009, pages
66-103.
Grievances and appeals data
AlohaCare will track and maintain records about the receipt
and handling of grievances and appeals. We will also disclose grievances and
appeals data to you upon request. To obtain this data, you should call
AlohaCare Advantage Customer Service Department at 973-6395 from Oahu or toll
free at 1-866-973-6395 from the Neighbor
Islands or Mainland or
you can visit us Monday through Friday, 8 a.m. ? 5 p.m. TTY users should call
1-877-477-5990.You can call 8 a.m.-8 p.m., Monday through Friday.
AlohaCare has contracted with the Centers for Medicare
& Medicaid Services to offer AlohaCare Advantage a Medicare Advantage Plan.
Transition policy for level of care changes
AlohaCare, upon notification
will cover up to a sixty (60) day supply of a prescription drug (unless written
for less) for current members who have a level of care change. A level of care
change includes the following situations:
- if you enter a long-term care facility from a
hospital or other setting;
- if you leave a long-term care facility to return
to a community/home setting;
- if you are discharged from a hospital to a
community/home setting;
- if you end your skilled nursing facility stay
covered under Medicare Part A and need to revert to coverage under
AlohaCare Advantage;
- if your hospice status reverts to standard
Medicare Part A and B benefits; or,
- if you are discharged from a psychiatric
hospital with a drug regimen that is highly individualized.
AlohaCare may make
arrangements to continue to provide necessary drugs beyond the 90 day
transition period, because of your coverage determination, formulary exception
request or appeal that is in-process.
Where
do I go for more information?
The Centers for Medicare & Medicaid Services
(CMS) prepares information to help explain general questions about Medicare
prescription drug coverage, we will update this list from time to time.
Please check back to see if we have new information to share with you.
Here are some fact sheets you might find helpful:
What drugs do Medicare
Drug Plans Cover?
How new
Medicare drug plans will provide you with high-quality, lower-cost drug
coverage
Medicare
Prescription Drug Coverage: How to file a complaint, Coverage
Determination, or Appeal
Best
Available Evidence (BAE) Policy (By
clicking on the link, you will be leaving the AlohaCare web site.)