Your Rx Drug Benefit for 2017
As a member of AlohaCare Advantage Plus (HMO SNP), you are automatically qualified for "Extra Help" to pay for your prescription drug costs. This is also called "Low Income Subsidy" or LIS.
With Extra Help from Medicare, depending upon your income and institutional status, you pay:
$0 or $1.20 or $3.30*
For all other drugs:
$0 or $3.60 or $8.25*
* All cost sharing is based on your level of Medicaid eligibility. Contact Medicaid for details.
Low Income Subsidy or “Extra Help”
If you have limited income and resources, you may be able to get Extra Help. Because you are eligible for QUEST Integration (Medicaid), you qualify for and are getting "Extra Help" from Medicare to pay for your prescription drug plan costs. You do not need to do anything further to get this "Extra Help." Extra Help may pay for your monthly premium, yearly deductible, prescription coinsurance and copayments. Premiums include coverage for both medical services and prescription drug coverage. This does not include any Medicare Part B premium you may have to pay. The 2017 Low Income Premium Table shows you what your monthly plan premium will be with extra help.
With "Extra Help", Medicare pays for your prescription drug plan costs. The Medicare Coverage Gap Discount Program does not apply to you. You already have coverage for your prescription drugs during the coverage gap through the "Extra Help" program. Please see Chapter 6 of the Evidence of Coverage that explains the various stages of drug coverage.
If you have questions about "Extra Help," call:
- 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7 days a week;
- The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call, 1-800-325-0778; or
- Your State Medicaid Office.
Medication Therapy Management (MTM) Programs
Medication Therapy Management (MTM) programs are available to you at no additional cost if you have multiple medical conditions, taking many prescription drugs, and have high drug costs.
If you have at least three chronic diseases or are taking at least seven different drugs or spend $3,919 or more per year on Part D covered medications, you are eligible for the MTM program. The following chronic diseases apply:
- Chronic Heart Failure (CHF)
- Chronic Obstructive Pulmonary Disease (COPD)
- End-Stage Renal Disease (ESRD)
- High blood fat levels
- High blood pressure
AlohaCare Advantage Plus contracts with Express Scripts, the AlohaCare Pharmacy Benefit Manager, to provide this free program to you. This program gives you access to the personal services of an Express Scripts pharmacist who can help look out for your health and safety. In addition, an Express Scripts Medicare Advisor is available to ensure you get the most value from your benefit plan. Though, our programs are not considered a plan benefit, these MTM programs help us provide better coverage for our members.
For information about the MTM Program or to see if you qualify, you can call our Member Services at 1-866-973-6395, 8 a.m. to 8 p.m., 7 days a week. TTY/TDD users call 1-877-447-5990.
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, the prescription is filled at a network pharmacy, and other coverage rules are followed. We may add or remove drugs from our formulary during the year.
2017 Comprehensive Formulary (updated 4/2017)
Are there any restrictions or limitations?
Some covered drugs may have additional requirements or limits on coverage. These limitations are marked next to each drug on the formulary with "BvsD," "LA," "PA," "QL" or "ST."
• Part B versus D (BvsD): This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
- Limited Access (LA): This prescription may be available only at certain pharmacies.
- Prior Authorization (PA): You may need prior authorization for certain drugs that are on the formulary or drugs that are not on the formulary, which requires prior approval through our formulary exception process described below. This means that you will need to get prior approval before you fill your prescriptions. If you do not get approval, we may not cover the cost of your drug.
- Quantity Limit (QL): For certain drugs, AlohaCare Advantage Plus limits the amount of the drug that we will cover per prescription or for a defined period of time. For example, we will provide up to 18 tablets per 30-day period for Imitrex� 50mg.
- Step Therapy (ST): In some cases, AlohaCare Advantage Plus 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.
If you are a new member of AlohaCare Advantage Plus, you may be taking drugs that are not on our Formulary or that are subject to certain restrictions. Or, you may be a current member and are affected by changes to our Formulary from one year to the next. You should speak with your doctor to decide if you should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug.
- Temporary supply of the non-formulary drug if you need a refill for the drug during the first 90 days of your membership.
- Temporary supply of the non-formulary drug if you need a refill for the drug during the first 90 days of the new plan year.
- For drugs that are not on our formulary, or that have coverage restrictions or limits (but is otherwise considered a “Part D drug”), we will cover a 30-day supply.
- If you are a new member and are a resident of a long-term-care facility (like a nursing home), we will cover a temporary 31-day transition supply (unless the prescription is written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days you are enrolled in our plan.
- If you have been enrolled in AlohaCare Advantage Plus for more than 90 days and need a drug that is not on our formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 31-day emergency supply of that drug while you pursue a formulary exception.
Last updated 4/1/2017. Please contact AlohaCare for more information.