Pharmacy Information
Please click on the questions below to receive more
information on how AlohaCare Advantage's Plus drug coverage works.
What is the
AlohaCare Advantage Plus 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 Plus 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?
Transition policy for level of
care changes.
Where do I go for more
information?
What is the AlohaCare Advantage Plus Formulary?
A formulary is a list of drugs selected by AlohaCare
Advantage Plus 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 Plus 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 Plus 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 AlohaCare Advantage Abridged Formulary 2008/2009
is our partial formulary that includes only some of the drugs covered by
AlohaCare Advantage Plus.
Our Comprehensive Formulary 2008/2009
is a complete listing of all prescription drugs covered by AlohaCare Advantage
Plus
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 Plus 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 Pharmacy Directory 2008/2009
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 Plus 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 Abridged Formulary 2008/2009
and Comprehensive Formulary 2008/2009
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 Plus 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 Plus before you fill your
prescriptions. If you don't get approval, AlohaCare Advantage Plus may
not cover the drug.
Quantity
Limit (QL): For certain drugs,
AlohaCare Advantage Plus limits the amount of the drug that AlohaCare Advantage
Plus will cover. For example, AlohaCare Advantage Plus provides 18 tablets
per prescription for Imitrex® 50 mg.
Step
Therapy (ST): In some cases,
AlohaCare Advantage Plus 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 Plus may not cover Singulair unless you
try Flonase; first. If Flonase does not work for you, AlohaCare Advantage Plus
will then cover Singulair;.
You can ask AlohaCare Advantage Plus for drug
coverage review to these restrictions or limits by completing our Request for Medicare Prescription Drug Coverage Determination
Form and faxing 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 Plus 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 Plus. 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 Plus.
2. You can ask AlohaCare Advantage Plus 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 Plus
Formulary?
You,
your physician or your "Authorized Representative" can ask AlohaCare Advantage
Plus 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 Plus 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 96814
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. This appeal is called a request for reconsideration. 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 Evidence of Coverage 2008/2009.
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 Plus, Customer Service
1357 Kapiolani
Blvd. Suite 1250
Honolulu, HI 96814
You may also refer to your AlohaCare Advantage
Plus Evidence of Coverage 2008/2009, pages 87 -
120.
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.)