Prescription Drugs

How much will my drugs cost?

You pay nothing for prescribed drugs that are on AlohaCare's list of covered drugs. These drugs are covered in full by your AlohaCare QUEST (Medicaid) plan.

What is covered?

Prescription medicines are covered at no cost to you when:

Your doctor gives you a prescription for a drug and the drug is listed on the AlohaCare QUEST (Medicaid) Formulary.
- The AlohaCare QUEST (Medicaid) Formulary is a list of preferred drugs that are covered by AlohaCare.
- You can search our Drug Finder to find these formulary drugs.
We approve your non-formulary drug as an exception request.
You are started on a drug while you are in an emergency room or hospital.
You receive the drug while in a rest home, nursing home, or convalescent hospital and it is ordered by a doctor for a covered service.
You get them through a pharmacy in the AlohaCare Pharmacy Network.

Drugs That Are Not Covered by AlohaCare QUEST (Medicaid)

Some drugs are not covered under the Med-QUEST program, such as:

Drugs used for cosmetic purposes
Drugs used for erectile dysfunction
Drugs used for fertility
Drugs related to food supplements
Vaccines for travel
Experimental drugs or drugs used in an experimental manner
Drugs not approved by the Food & Drug Administration (FDA)
Bulk powder drugs

Some drugs are covered through Med-QUEST Division instead of AlohaCare. This is called a carve-out drug. Your pharmacy must bill the prescription to MedQUEST instead of AlohaCare. Some carve-out medicines are:

Drugs to help with dying
Zolgensma, a drug used for a severe muscle condition
Dental drugs or drugs given to you by a dentist or oral surgeon for emergency use in adults.

Generic Medications

If you doctor orders a brand name drug, and there is a generic available, AlohaCare will cover the generic medication. If your doctor says that you must have the brand name drug instead of the generic, they must submit a prior authorization request to OptumRx. OptumRx is AlohaCare's partner for pharmacy drug coverage.

Extended Days' Supply

AlohaCare allows members to receive up to a 100-day supply of generic medicines such as for certain disease states such as:

blood pressure;
diabetes; and
cholesterol.

You can search our Drug Finder to view a complete list of drugs that we cover at an extended day's supply.

Drug Recalls and Withdrawals (removed from market)

The U.S. Food and Drug Administration (FDA) is responsible for ensuring drugs are tested to be safe and effective before they become available. Sometimes there can be a drug recall or market withdrawal. A market withdrawal is when a drug company removes a product from the market. This can happen for various reasons. Two examples are product tampering or correcting a minor violation. A drug recall occurs when a drug is removed from the market because it is deemed to be defective or possibly harmful.

There are 2 types of recalls required by the FDA. It is based on the level of danger involved:

Class I: Dangerous or defective products that could cause serious health problems or death. Example: a label mix-up on a lifesaving drug.
Class II: Products that might cause a short-term health problem or pose only a slight threat of a serious nature. Example: a drug that is under-strength but that is not used to treat life-threatening illness.

AlohaCare’s Pharmacy department will tell members, doctors and pharmacies when there is a Class I or II drug recall. We also inform our members in writing when drugs are withdrawn from the market for safety reasons. AlohaCare reviews drug recalls and withdrawals during a Drug Utilization Review (DUR) meeting every 3 months.

Please talk to your doctor or pharmacist about any details on drug recalls and withdrawals that may affect you.

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January 1 - March 31

April 1 - June 30

July 1 - September 30

October 1 - December 31

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January 1 - March 31	January 1 - March 31	January 1 - March 31	January 1 - March 1
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July 1 - September 30	July 1 - September 30	July 1 - August 31	July 1 - September 30
October 1 - December 31	October 1 - December 31	September 1 - October 31	October 1 - December 31

Getting an Exception to the Formulary

Drugs not listed on the formulary are called non‐formulary drugs. For non‐formulary drugs, you can:

Ask your doctor to order a similar drug that is listed in the formulary.
Ask your doctor to request an exception so your non‐formulary drug can be covered by AlohaCare.
Ask for an exception to cover a non‐formulary drug by sending us a Member Prescription Drug Prior Authorization Request Form . You can also call Customer Service at (808) 973-0712 or toll free at 1-877-973-0712 (TTY/TDD at 1-877-447-5990), 24 hours a day, 7 days a week.

Reimbursement Requests

You should not have to pay for your medicine at your pharmacy. If you pay for your medicine because you do not have your insurance card, you can ask OptumRx to reimburse you. OptumRx will review your reimbursement request. OptumRx will make a decision within 14 days after they have received your request. You must send in your prescription receipt and itemized printout from the pharmacy. Your request must have the following:

Your name
Prescription number
Date filled
Pharmacy name and address
Drug name, strength/form, and quantity received
Ingredient cost, gross amount due
Days’ supply
Price

How Can I Request Reimbursement for My Drugs?

You can submit your reimbursement request by filling out the Prescription Reimbursement Claim Form and mailing it to:

OptumRx Claims Department

P.O. Box 650334

Dallas, TX 75265-0334

Diabetes Meters

Diabetes glucose meters are covered by the drug manufacturer. It is not covered by AlohaCare. To have a meter delivered to your home, please call the True Metrix Free Meter Fulfilment Center: 1-866-788-9618, Monday through Friday between 9AM-5PM EST. Or, ask your doctor to send a prescription for a TRUE METRIX or TRUE METRIX AIR glucose meter to your pharmacy. Your pharmacy can bill the drug manufacturer for the meter. To have a pharmacy give you a free meter, give your pharmacist these numbers:

BIN: 018844 | PCN: 3F | ID : TRPT5023493 | Group : FVTRUEPORT50

Pharmacy Network

AlohaCare has a network of pharmacies that can fill your medicines.

Pharmacy Finder

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.

Out-of-Network Pharmacy

AlohaCare only works with pharmacies in Hawai’i. Pharmacies outside of Hawaiˊi are not in AlohaCare’s pharmacy network. If you need to use a pharmacy on the mainland (out of area), you will need to ask AlohaCare to add an override to let you use that pharmacy. Prescriptions may be covered on the mainland (out of area) for emergency or urgent services only. AlohaCare will review your request on a case-by-case basis for medical necessity. You can call Customer Service at (808) 973-0712 or toll free at 1-877-973-0712 (TTY/TDD at 1-877-447-5990), 24 hours a day, 7 days a week.

Specialty Drugs

Specialty drugs are usually high cost medicines used to treat complex or rare conditions. OptumRx Specialty Pharmacy will provide your specialty drugs. Your doctor or pharmacy will know if a drug needs to be filled at a Specialty Pharmacy.

OptumRx Specialty Pharmacy has nurses and pharmacists who can talk with you about your condition and how to use your medicine. OptumRx will deliver specialty drugs to your home.

If you need help with your specialty drugs, call OptumRx Specialty Pharmacy toll free at 1-833-329-1247 (TTY 711). You can also call Customer Service at (808) 973-0712 or toll free at 1-877-973-0712 (TTY/TDD at 1-877-447-5990), 24 hours a day, 7 days a week.

Mail Order & Home Delivery

We understand that going to the pharmacy every day can be hard sometimes. AlohaCare is offering the convenience of home delivery of your medicine. With OptumRx Home Delivery Pharmacy, you can request for drugs you take on a regular basis be delivered to your home. These include drugs that you take every day to treat your condition, such as diabetes, high blood pressure, or asthma.

Ask your doctor if your drug can be filled by Optum Home Delivery Pharmacy. To sign up for home delivery, please mail in the OptumRx New Home Delivery Prescription Order Form found on the Member Documents page . If you need help with your Home Delivery drugs, call OptumRx Home Delivery toll free at 1-833-396-0309. You can also call Customer Service at (808) 973-0712 or toll free at 1-877-973-0712 (TTY/TDD at 1-877-447-5990), 24 hours a day, 7 days a week.

To order a refill for an existing, unexpired Home Delivery prescription, filled by OptumRx Home Delivery Pharmacy, log into the Pharmacy Member Portal (by OptumRx) .

Lock-In Program

The AlohaCare Lock-In Program helps you use prescription opioids safely. Opioids can have serious risks like addiction, overdose, and death. These risks are increased when you get opioids from multiple doctors or pharmacies. If you get opioids from multiple doctors or pharmacies, you may be enrolled in the AlohaCare Lock-In Program.

The AlohaCare Lock-In Program requires you get your prescription opioids from one doctor or clinic and one pharmacy. We will not cover these medications if they are prescribed by other doctors even if the other doctor is 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 your access to prescription opioids. Your access to other types of medications will not change.

Want more information? Visit www.hhs.gov/opioids for State and Federal public health resources. These resources can help you learn more about opioids and how to use them safely.

How Do I Get Care?

Call Customer Service at (808) 973-0712 or toll free at 1-877-973-0712 (TTY/TDD at 1-877-447-5990), 24 hours a day, 7 day a week. We can help with:

Questions about a drug.
Any problems with getting prescription(s) filled at the pharmacy. (Your prescriptions should be no cost to you so please do not pay for any prescriptions).
You are not in Hawaiˊi and need to fill a prescription. Prescriptions are covered through AlohaCare's network pharmacies within Hawaiˊi. Prescriptions may be covered outside of Hawaiˊi for emergency or urgent services only.
You need an interpreter to talk with the pharmacy about getting your medication.
You have an emergency and need drugs. AlohaCare will provide you with up to a 7-day supply of the drug.

Pharmacy Questions & Answers (Q&A)

Q. How does AlohaCare decide which drugs to put on the formulary list?

A. The drugs on this list are chosen by the Pharmacy and Therapeutics (P&T) Committee. This committee is a team made up of doctors and pharmacists from AlohaCare. They also get input from the medical community. The P&T committee meets every 3 months to decide which drugs should be on the list. The drugs chosen are the ones that will serve you best. The P&T committee also reviews Food and Drug Administration (FDA) reports. These reports talk about new drugs approved for use and how well current drugs work. These reports help the committee know if they should add or remove drugs from the list.

Q. What is Prior Authorization?

A. Certain drugs require a prior authorization. That means that AlohaCare may have to approve a drug your doctor wants you to take before AlohaCare will pay for the drug. We only do this with some drugs. We may ask for it if:

Our formulary drug list says the drug is “PA” or prior authorization is needed.
The drug is not on our list.
The drug is being used for a health condition that the Food and Drug Administration (FDA) did not approve.
The prescription is being refilled too soon after it was first filled. For example, if your drug is lost, stolen or spilled, you might need a prior authorization to get an early refill. Or, you might also need it if you go on vacation and need extra medicine for a long trip. A prior authorization is also needed if your doctor changes you to a higher dose of the drug you are already taking.

Your doctor will send us a prior authorization request if you need to take a drug that requires prior authorization. AlohaCare uses OptumRx to review those requests. Your doctor will explain why you need to take that drug. OptumRx will review the request. They will tell your doctor within 24 hours if the request has been approved. They will tell you, your doctor, and your pharmacy if the drug was approved. OptumRx will send a letter to you and your doctor if the prior authorization request was denied along with an explanation of their decision. They will explain their decision. They will also tell you ways that the decision can be changed. You can check with your doctor's office if a decision has been made regarding any prior authorization requests. Your doctor will have information about all your prescriptions and final decisions regarding prior authorizations.

Q. Why do we have a Prior Authorization process?

A. We ask for prior authorization to make sure:

A drug is safe for you to take.
You take the right amount of the drug.
The drug is a good drug to treat your condition.
It was prescribed to you by the right person.
The drug will not mix in a dangerous way with any other drugs you take.
An expensive drug prescribed by your doctor is necessary when there is a less expensive drug that will work for your condition.

Q. What is a utilization control?

A. We want to keep you safe when you take your medicine. Utilization controls are rules in the pharmacy computers for certain drugs. These are alerts for your pharmacist to make sure that the drug is safe for you. These rules will limit whether or not you can take a certain drug and how much you can take. These rules will make sure the drug will help you and not hurt you.

Types of utilization controls

Dose/Age Check: This check is to make sure that you take the right amount of a drug for your age, weight, and height. The FDA has directions for how much of a drug a person of a certain age, weight, and height can take. We have dose/age checks to make sure the drug you are prescribed follows these directions.

Drug Interaction Screens : Some people see more than one doctor. Each doctor may prescribe a different type of drug for you. Sometimes the different drugs taken together can be dangerous to your health. That is why the pharmacy computers do drug interaction screens. These screens check to make sure the drug you are prescribed will not interact with another drug you take. If the pharmacy notices a problem, they will tell you and your doctor.

We want to keep you safe. That is why we follow these processes. We do not want you take a drug if there is a danger. We also conduct drug utilization reviews. Our pharmacy computers review your drug records each time you fill a prescription. We make sure there is no problem with the drugs you take.