AlohaCare Advantage Plus (HMO SNP)
Part D Prescription Drug Benefit
Your Rx Drug Benefit
As a member of AlohaCare Advantage Plus, you are automatically qualify for 'Extra Help' to pay for your prescript drug costs. This is also called enrolled 'Low Income Subsidy' or LIS.
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Full Amount
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With Extra Help from Medicare, depending upon your income and institutional status, you pay:
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Deductible $0
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$0
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Generic 25%
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$0 or $1.10 or $2.60*
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Brand 25%
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$0 or $3.30 or $6.50*
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* All cost sharing is based on your level of Medicaid eligibility. Contact Medicaid for details.
Low Income Subsidy or “Extra Help”
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help or if you would like to inquire about your LIS status or level, call:
- 1-800-MEDICARE (1-800-633-4227). TTY 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 users should call, 1-800-325-0778; or
- Your State Medicaid Office.
People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877- 486-2048.
To see how much premium would be if you qualified for Extra Help, look at the 2012 Low Income Premium Table.
What is the Formulary?
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. AlohaCare Advantage Plus may add or remove drugs from our Formulary during the year. To see if we cover your drugs, look at your
2012 Comprehensive Formulary or use the Drug Finder Tool on this webpage.
What are drug tiers?
Drugs on our Formulary are organized into different drug tiers, or groups of different drug types. Your copayment depends on which drug tier your drug is in. You may ask AlohaCare Advantage Plus to make an exception (which is a type of coverage determination) to your drug’s tier placement. For additional information, please refer to the section below on how to request an exception.
Are there any restrictions or limitations?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. 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 from AlohaCare Advantage Plus 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.
Can the formulary change?
AlohaCare Advantage Plus may add or remove drugs from the formulary during the year. If we remove a drug from the formulary or add a prior authorization, quantity limit, step therapy, or other restriction on a drug that moves it to a higher cost-sharing tier, and you are taking the drug affected by the change, you will be permitted to continue taking that drug at the same level of cost-sharing for the remainder of the plan year. However, if a brand name drug is replaced with a new generic drug, or our formulary is changed as a result of new information on a drug’s safety or effectiveness, you may be affected by this change.
AlohaCare Advantage Plus will provide you with a 60-day notice prior to the effective date or provide you with a 60-day supply of the affected medication the next time you pick up the affected medication at the pharmacy. This will give you an opportunity to work with your physician to switch to a different drug that we cover or request an exception. If a drug is removed from our formulary because the drug has been recalled from the pharmacies, we will not give 60 days notice before removing the drug from the formulary. Instead, we will remove the drug immediately and notify you about the change as soon as possible.
Look below for monthly updates to the 2012 AlohaCare Advantage Plus Formulary.
If your drug is not listed on our formulary, you should first check the formulary on our website which we update monthly (if there is a change). In addition, you may contact Customer Service to be sure it isn’t covered. If Customer Service confirms that we do not cover your drug, you have two options:
- You may ask your doctor if you can switch to another drug that we cover; or,
- You or your doctor may ask us to make an exception (a type of coverage determination) to cover your drug. If the exception isn’t approved, you may appeal our denial. For more information, see the section below on how to request an exception or appeal.
If you recently joined AlohaCare Advantage Plus, you will receive a temporary supply of a drug you were taking when you joined our plan if it is not on our formulary. For more information, please refer to our Transition Policy provided below.
Which pharmacies can I use?
You must use network pharamcies to access your prescription drug benefit, excpet in nonroutine circumstances. A network pharmacy is a pharmacy that we have contracted with to provide you with your covered prescription drugs. Types of pharmacies included in our network are: Retail, Chain, Mail Order, LTC and Home Infusion. Chances are the pharmacy you currently use to pick up your drugs is in our pharmacy network. Our pharmacy network includes 205 pharmacies which equals or exceeds CMS requirements for pharmacy access in your area. Look at your
2012 Provider/Pharmacy Directory for a listing of our network pharmacies.
What is mail-order prescription drug service?
You can get your prescription drugs mailed to your home. Our mail-order prescription drug service requires you to order at least a 30-day supply of the drug and no more than a 90-day supply. Usually a mail-order pharmacy order will get to you in no more than 13 – 15 days. However, sometimes your mail-order may be delayed. Make sure you have at least an 18-day supply of that medication on hand. If you don’t have enough, ask your doctor to give you a second prescription for a 30-day supply and fill it at a network retail pharmacy while you wait for your mail-order supply to arrive. To get order forms and information about filling your prescriptions by mail, call 1-800-501-6763. TTY/TDD users should call 1-800-716-3231. You can also call Customer Service at the numbers listed at the bottom of this webpage.
What if I need to fill my prescriptions at an out-of-network pharmacy?
Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:
- When you travel or are away from our service area.
- When you have a medical emergency of because you needed urgent care.
- Other times you can fill prescriptions outside the network if at least one of the following applies:
- If you are unable to obtain a covered drug in a timely manner within our service area because there is not a network pharmacy within a reasonable driving distance that provides 24-hour service;
- If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail or mail-order pharmacy (including high cost and unique drugs) or;
- If you are getting a vaccine that is medically necessary and covered by Medicare Part D but not covered by Medicare Part B that are administered in your doctor’s office.
Transition Policy
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, such as prior authorization or step therapy. 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.
During the period of time when you are talking with your doctor to determine the right course of action, we will provide a temporary supply of the non-Formulary drug if you need a refill for the drug during the first 90 days of your membership. If you are a current member affected changes to our Formulary from one year to the next, we will provide a 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.
When you go to a network pharmacy and AlohaCare Advantage Plus provides a temporary supply of a drug that is not on our Formulary, or that has coverage restrictions or limits (but is otherwise considered a “Part D drug”), we will cover a 30-day supply (unless the prescription is written for fewer days). After we cover the temporary 30-day supply; generally, we will not pay for these drugs as part of our transition policy again.
We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.
If you are a new member and is 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 (unless the prescription is for fewer days) while you pursue a formulary exception.
Transition policy for level of care changes
Upon notification, we 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 Plus;
- 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.
We 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. Please note that our transition policy applies only to those drugs that are “Part D drugs” and picked up at a network pharmacy. The transition policy cannot be used to buy a non-Part D drug or a drug out-of-network, unless you qualify for out-of-network access.
How do I request a coverage determination?
A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your drugs. You, your representative or your doctor can ask for a coverage decision. For example, if you want to know if we will cover drug before you receive it, you can ask us to make a coverage decision for you. We will make a coverage determination within 72 hours. You can ask for an expedited review and we will make a decision within 24 hours.
You can request a coverage determination verbally or in writing.
AlohaCare Advantage Plus Customer Service
1357 Kapiolani Blvd. Suite 1250
Honolulu, HI 96814
Fax: (808) 973-0726
Call: 973-6395
Toll-free: 1-866-973-6395
TTY: 1-877-477-5990
8 a.m. to 8 p.m., 7 days a week
If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. When we have completed the review we give you our decision.
How do I request an exception to the formulary?
If a drug is not covered in the way you would like it to be covered, you can ask the plan to make an “exception.” An exception is a type of coverage decision.
When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request. Here are three examples of exceptions that you or your doctor or other prescriber can ask us to make:
- Covering a Part D drug for you that is not on our formulary.
- Removing a restriction on our coverage for a covered drug.
- Changing coverage of a drug to a lower cost-sharing tier.
To request an exception, you, your representative or your doctor can call, write or fax us to make your request. Make sure you submit supporting information, such as your medical records, to help us make a decision. Your doctor can fill out the
Medicare Part D Coverage Determination Form and submit it to us. We will make a decision within 72 hours. You can ask for an expedited review and we will make a decision within 24 hours.
AlohaCare Advantage Plus Customer Service
1357 Kapiolani Blvd. Suite 1250
Honolulu, HI 96814
Fax: (808) 973-0726
Call: 973-6395
Toll-free: 1-866-973-6395
TTY: 1-877-477-5990
8 a.m. to 8 p.m., 7 days a week
How do I request an appeal?
An appeal to the plan about a Part D drug is also called a plan "re-determination." To start your appeal, you, your representative or your doctor must contact us by phone, fax or in writing. You can also fill out our
Retermination Form and submit it to us.
We will make a decision within seven days. If your health requires a quick response, you may ask for an “expedited appeal.” If we are using the expedited deadlines, we will give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it.
AlohaCare Advantage Plus Customer Service
1357 Kapiolani Blvd. Suite 1250
Honolulu, HI 96814
Fax: (808) 973-0726
Call: 973-6395
Toll-free: 1-866-973-6395
TTY: 1-877-477-5990
8 a.m. to 8 p.m., 7 days a week
What if my "re-determination" request is not approved and I do not agree with the decision?
You or your 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 independent review organization has no connection to AlohaCare Advantage Plus.
MAXIMUS
Part D QIC
50 Square Dr
Victor, NY 14564
Call: (585) 425-5300
Toll-free: 1-877-456-5302
Fax: (585) 425-5301
Toll-free: 1-866-825-9507
Drug Utilization Review
AlohaCare Advantage Plus conducts drug utilization reviews for all of our members to ensure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe their medications. We conduct a drug utilization review each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:
- Possible medication errors;
- Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition;
- Drugs that are inappropriate because of your age or gender;
- Possible harmful interactions between drugs you are taking;
- Drug allergies; or,
- Drug dosage errors.
If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.
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 and taking at least eight different drugs, you are eligible for the MTM program. The following chronic diseases apply:
- Bone Disease-Arthristis-Osterporosis
- Respiratory Disease-COPD
- Chronic Heart Failure
- Mental Health-Depression
- Diabetes melitus
- Dyslipidemia
- Hypertension
AlohaCare Advantage Plus contracts with Medco, the AlohaCare Pharmacy Benefit Manager, to provide this program to you. This program gives you access to the personal services of a Medco pharmacist who can help look out for your health and safety. In addition, a Medco 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 additional information about our MTM program or other quality assurance policies and procedures, contact Customer Service at the numbers listed at the bottom of this webpage.
What if I have a complaint about the Prescription Drug Plan?
A type of complaint is called a “grievance.” You can make a grievance about us or one of our network providers or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.
Some examples of why you might file a grievance include:
- Problems with the service you receive from Customer Service;
- Waiting too long for your prescriptions to be filled; or
- Problems with getting appointments when you need them, or waiting too long for them.
To file a grievance, you can call, write or fax us.
AlohaCare Advantage Plus Customer Service
1357 Kapiolani Blvd. Suite 1250
Honolulu, HI 96814
Fax: (808) 973-0726
Call: 973-6395
Toll-free: 1-866-973-6395
TTY: 1-877-477-5990
8 a.m. to 8 p.m., 7 days a week
You may complain to us using the grievance process, to an independent review organization called the Quality Improvement Organization (QIO). 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 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 St, Suite 501
Honolulu, HI 96814
Fax: (808) 440-6030
Call: (808) 545-2550
Toll-free: 1-800-525-6550
Who do I contact if I have questions about the grievance, coverage determination, exception or appeals process or the status of my coverage determation or appeal?
You may contact Customer Service by phone or in writing:
AlohaCare Advantage Plus Customer Service
1357 Kapiolani Blvd, Suite 1250
Honolulu, HI 96814
Call: 973-6395
Toll-free: 1-866-973-6395
TTY: 1-877-477-5990
8 a.m. to 8 p.m., 7 days a week
You can also reference
Chapter 9 in your Evidence of Coverage for more information about grievances, coverage determinations (including exceptions) and appeals processes.
Grievances and Appeals Data
AlohaCare Advantage Plus tracks and maintains records about the receipt and handling of organization or coverage determinations (including exceptions), appeals and grievances. We will disclose this information to you upon request. To obtain this data, call Customer Service at the numbers listed at the bottom of this webpage.
Where can 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. 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 Policy: Best available evidence policy is used when the low-income subsidy information in CMS’ systems is not correct. CMS relies on monthly files from the states and Social Security to establish an individual’s low-income subsidy deemed eligibility and appropriate cost-sharing level. In certain cases, CMS systems do not reflect a beneficiary’s correct LIS deemed status. This may occur, for example, because a state has been unable to successfully report the beneficiary as Medicaid eligible or is not reporting him/her as institutionalized.
Contact Us
If you have any questions or for additional network pharmacy information, call Customer Service at 973-6395 or toll-free at 1-866-973-6395, 8 a.m. to 8 p.m., 7 days a week. TTY users can call 1-877-447-5990.