Formulary
AlohaCare QUEST (Medicaid) Formulary
AlohaCare covers all medically necessary Med-QUEST-covered medications. We use a Formulary, which is a list of the drugs that we prefer our providers to prescribe. AlohaCare also covers the over-the-counter drugs listed on our Formulary. Your patient will need a prescription for an over-the-counter drug to be covered by AlohaCare.
You can search our
Drug Finder to find drugs that are on our Formulary.
Requests will be presented at CarelonRx's next Pharmacy & Therapeutics (P&T) Committee meeting for review and consideration.
Some drugs require a prior authorization (PA) to explain to us why a specific medication or a certain amount of a medication is needed. We must approve the request before the member can get the medication. Reasons why we may prior authorize a drug includes, but is not limited to:
- There is a generic or pharmacy alternative drug available;
- The drug can be misused/abused; or
- There are other drugs that must be tried first.
Some drugs may also have a quantity (amount) limit or an age limit.
Drugs for erectile dysfunction, infertility, and cosmetic purposes are not covered.
For a complete list of non-covered and excluded drugs, please see our Formulary document, under "Drugs That Are Not Covered by AlohaCare QUEST Integration."
Electronic prior authorization (ePA) is preferred method for PA submission for AlohaCare QUEST Integration.
Alternatively, prescribers can send requests using their current electronic health record/electronic medical record (EHR/EMR) system or submit a Prescription Drug Prior Authorization Request Form or Physician Administered Drug Request Form that can be found under Pharmacy Forms on the Provider Forms page.
AlohaCare requires the use of generic drugs if they are available. If you believe that it is medically necessary for your patient to have a brand name drug, you may submit a prior authorization request for review. CarelonRx will determine whether to approve the brand name medication.
Our formulary and list of medications that require prior authorization can change, so it is important for you or your patient to check this information when your patient needs to fill or refill a medication.
For our member’s convenience and to encourage medication adherence, we cover up to a 100-day supply of generic maintenance medications. You can search our
Drug Finder to find drugs eligible for this extended supply.
For members with Community Care Services (CCS) benefits, certain drugs must be billed to CCS. These drugs include, but is not limited to:
- Drugs used for behavior health
- Drugs used for drug or alcohol addiction
Please refer to the CCS website for more information.
See below for a summary of drug recalls and withdrawals:
Please refer to the Provider Advisories page for Drug Safety Communication Alerts.
Pharmacy Billing Information
For billing primary AlohaCare QUEST Integration:
BIN: 020396 | PCN: IRXMCAID |GROUP: RX42AC
For billing secondary AlohaCare QUEST Integration:
QUEST Integration is the payer of last resort. For coordination of benefits (COB) billing for members with multiple prescription drug plans, bill other plan as primary plan and QUEST Integration plan (AlohaCare member ID starts with zeroes) as secondary plan.
For billing primary Medicare & secondary QUEST Integration, use:
BIN: 020396 | PCN: IRXCOBPR | GROUP: RX42AC
For billing primary commercial & secondary QUEST Integration, use:
BIN: 020396 | PCN: IRXCOMAP | GROUP: RX42AC
Limited Income Newly Eligible Transition Program (LI NET) LINET is a Medicare program that provides immediate prescription coverage for Medicare beneficiaries who qualify for Medicaid or the Low-Income Subsidy (LIS) and have no prescription drug coverage. Enrollment in LINET is temporary, usually for 1 to 2 months, to provide time to choose a Medicare Part D prescription drug plan. For AlohaCare QUEST members who are Medicare-eligible, but not enrolled in a prescription drug plan (confirm by submitting an E1 transaction to Medicare's online eligibility/enrollment system), bill claim using the following:
BIN: 015599 | PCN: 005440000 |GROUP: may be blank |
Cardholder ID: Medicare Claim Number (include letters) [from Medicare red, white, & blue card] | Patient ID (optional): Medicaid ID or Social Security Number
For questions about pharmacy processing and claim overrides, contact the CarelonRx Pharmacy Help Desk or visit
https://www.caremark.com/pharmacists-medical-professionals.html .
AlohaCare covers partial fills to synchronize medication refills to the same day each month. This only applies to maintenance medications that are normally covered for the member (the medication is on the formulary without restrictions or the member has an active prior authorization) and excludes Schedule II and III controlled substances.
For refill date synchronization, the pharmacy should calculate the days’ supply needed in a partial fill so that future fills of maintenance medications will fall on the same day.
If a claims reject with NCPDP Reject Code 79 (Refill Too Soon), the pharmacy may override the reject with Submission Clarification Code (SCC) 61 (Synchronization Fill - Shortened Days Supply).
TRUE METRIX is the preferred brand for diabetes testing products for AlohaCare.
Prescribers: Send a prescription to your patient’s pharmacy for a TRUE METRIX or TRUE METRIX AIR glucometer, test strips, and lancets.
Pharmacies: For a no-charge TRUE METRIX glucometer, transmit claims to Change Healthcare using the following billing information:
BIN: 018844 | PCN: 3F | ID: TRPT5023493 | Group: FVTRUEPORT50
For pharmacy processing questions, please call the Healthcare Pharmacy Help Desk at
1-855-282-4888 . Once a free meter is processed for reimbursement, the claim cannot be submitted to any other third-party payer. Limit one meter per patient every 12 months.
Pharmacy Network
To find out if a pharmacy works with AlohaCare, use our online Provider Finder or download the Provider Directory found on the Member Documents page.
Pharmacy Clinical Programs and Services
Home Delivery is a new service that AlohaCare offers to our QUEST Integration members. With Home Delivery, members have the convenience of getting maintenance medications delivered directly to their home. The Home Delivery Program is administered through CarelonRx Pharmacy with Hawaii-based dispensing overseen by CarelonRx’s operational partner, CVS.
To send electronic prescriptions for home delivery/mail order select CarelonRx Pharmacy in your ePrescribing platform. Please note that the pharmacy address will display as Mount Prospect, Illinois, however, the dispensing pharmacy is located on Oahu.
CarelonRx Pharmqacy Phone: 833-396-0309 | Fax: 800-378-0323
AlohaCare’s specialty pharmacy services will be administered by CarelonRx Specialty Pharmacy with Hawaii-based dispensing overseen by CarelonRx’s operational partner, CVS/Caremark Specialty Pharmacy. With CarelonRx Specialty Pharmacy, members have the option to request for delivery to their home or for pick up at their neighborhood Longs Drugs store.
To send electronic prescriptions for specialty drugs, select CarelonRx Specialty Pharmacy in your ePrescribing platform. Please note that the pharmacy address will display as Orlando, Florida, however, the dispensing pharmacy is located on Oahu.
CarelonRx Specialty Pharmacy Call: Phone: 833-262-1726 | Fax: 833-263-2871
The AlohaCare Lock-In Program enrolls select members who are using more than an average daily 90 MME (morphine milligram equivalents) of opioids and receiving opioids from multiple prescribers and/or pharmacies. Members are required to obtain prescription opioids from one doctor or clinic and one pharmacy. Opioids will not be covered by AlohaCare if they are prescribed by other doctors or filled by other pharmacies, even if they are in our network. To request a different doctor, clinic, or pharmacy, please submit a Pharmacy Lock-In & Designated Prescriber Selection Form found on the
Member Documents page.
This change only affects access to prescription opioids. Access to other types of medications will not change. Visit
www.hhs.gov/opioids for State and Federal public health resources for more information.
General Resources & Contact Information
| Pharmacy benefit (pharmacy dispensed drugs) prior authorization requests & status inquiries |
CarelonRx Pharmacy Services (Prescribers Only)
- Phone: 1-833-324-2095
- Fax: 1-844-462-5176
- Hours: 24 hours, 7 days a week
|
| QUEST (Medicaid) claims processing or overrides |
CarelonRx Medicaid Pharmacy Help Desk (Pharmacies Only)
- Phone Number: 1-833-329-1245
- Hours: 24 hours, 7 days a week
|
| Medical benefit (physician administered drugs) prior authorization request & status inquiries |
AlohaCare Provider Customer Service
|
