AlohaCare Advantage Plus (HMO)
Part D Prescription Drug Benefit
Your Rx Drug Benefit
As a member of AlohaCare Advantage Plus, you are automatically enrolled in:
- Low Income Subsidy (the Federal pharmacy program)
- Smooth Transitions (the Hawaii State Pharmacy Assistance Program–HSPAP)
As a Smooth Transition member, the Hawaii State Pharmacy Assistance Program will assist you with paying for your co-payments up to $6.30. Remember to show your AlohaCare Advantage Plus ID card, Medicaid card and Smooth Transitions card at the pharmacy in order to receive assistance with you copayments.
|
Full Amount
|
With Medicaid and Extra Help from Medicare, depending upon your income and institutional status, you pay:
|
|
Deductible $310.00
|
$0 to $63.00*
|
|
Generic 25%
|
$0 to $2.50 or 15%*
Your Smooth Transitions Card will pay for this copay, up to $6.30 maximum.
|
|
Brand 25%
|
$0 to $6.30 or 15%
Your Smooth Transitions Card will pay for this copay, up to $6.30 maximum.
|
* 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. Generally, your premium will be lower once you receive Extra Help from Medicare.
To see how much your premium would be if you qualified for Extra Help, click on the Low Income Premium Table.
If you qualify for Extra Help, you get help paying for your monthly premium, yearly deductible, prescription co-insurance and co-payments and experience no gap in coverage. 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.
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for getting Extra Help, call:
- 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7days a week;
- The Social Security Office at 1-800-722-1213 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 seventy-five percent of 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 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.
What is the AlohaCare Advantage Plus Formulary?
The AlohaCare Advantage Plus 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 AlohaCare Advantage Plus covers your drug, please click on the link below or use the Drug Finder feature to the left.
What are drug tiers?
Drugs on the AlohaCare Advantage Plus Formulary are organized into different drug tiers, or groups of different drug types. Your co-payment 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. A team of doctors and pharmacists developed these requirements and limits for AlohaCare Advantage Plus to help us provide quality coverage to our members. These limitations are marked next to each drug on the formulary with "LA," "PA," "QL" or "ST."
Limited Access (LA): This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or call our Customer Service Department at 973-6395 from Oahu or toll-free at 1-866-973-6395 from Oahu, Neighbor Islands or the Mainland, Monday through Friday, 8 a.m. to 8 p.m. TTY/TDD users should call 1-877-447-5990.
Prior Authorization (PA): AlohaCare Advantage Plus requires you to get prior authorization (prior approval) for certain drugs. You may need prior authorization for 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, AlohaCare Advantage Plus may not cover the cost or 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.
You can ask AlohaCare Advantage Plus for a drug coverage review to these restrictions or limits by completing our
Request for Medicare Prescription Drug Coverage Determination Form. This information can be submitted by mail or fax to:
AlohaCare Advantage Plus
Pharmacy Management Department
1357 Kapiolani Blvd., Suite 1250
Honolulu, HI 96814
Fax #: (808) 973-0726
You can also verbally request an expedited or standard drug coverage review by calling our Customer Service Department at 973-6395 or toll-free at 1-866-973-6395 from Oahu, Neighbor Islands or Mainland.
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 limits, step therapy, or other restrictions 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 members taking the drug about the change as soon as possible.)
Please click on the link below for updates to the AlohaCare Advantage Plus 2010 Formulary.
What if my drug is not on the formulary?
If your drug is not listed on our formulary, you should first check the formulary on our website which we update at least monthly (if there is a change). In addition, you may contact AlohaCare Advantage Plus 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 is covered by AlohaCare Advantage Plus. If you would like to give your doctor a list of covered drugs that are used to treat similar medical conditions, please contact Customer Service or go to our formulary on our website; or,
- You or your doctor may ask us to make an exception (a type of coverage determination) to cover your drug. If you pay out-of-pocket for the drug and request an exception that we approve, AlohaCare Advantage Plus will reimburse you. If the exception isn’t approved, you may appeal the Plan’s denial. For more information please see the section below on how to request an exception or appeal.
In some cases, we will contact you if you are taking a drug that is not on our formulary. We can give you the names of covered drugs that also are used to treat your condition so you can ask your doctor if any of these drugs are an option for your treatment.
If you recently joined AlohaCare Advantage Plus, you will receive a temporary supply of a drug you were taking when you joined AlohaCare Advantage Plus if it is not on our formulary. For more information, please refer to our Transition Policy provided below.
Which pharmacies can I use?
To keep your costs low, you must use a network pharmacy to fill your drugs except under non-routine circumstances when you cannot reasonably use one of our network pharmacies. 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, 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 183 pharmacies statewide which equals or exceeds CMS requirements for pharmacy access in your area. Click on the link below to locate a pharmacy near you.
What is mail-order prescription drug service?
Our plan’s mail-order service requires you to order at least a 30-day supply of the drug and no more than a 90-day supply. 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, or visit www.medco.com. If you use a mail-order pharmacy not in the plan’s network, your prescription will not be covered. 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 retail network pharmacy while you wait for your mail-order supply to arrive. If your mail-order shipment is delayed, please call 1-800-501-6763. TTY/TDD users should call 1-800-761-3231. To obtain information regarding mail-order prescription drug service, call AlohaCare Customer Service at 1-866-973-6395. TTY/TDD users can call 1-877-973-6395.
What if I need to fill my prescriptions at an out-of-network pharmacy?
AlohaCare Advantage Plus may cover your drugs in certain instances if it is filled at an out-of-network pharmacy, including traveling to the mainland or for a medical emergency. We may also cover your drugs if you are unable to obtain your drugs within a timely manner, your prescription is not regularly stocked at a network pharmacy, if you are getting a vaccine that is medically necessary but not covered by Medicare Part B, plus some covered drugs that are administered in your doctor’s office.
If you are traveling within the United States or territories and become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy. In this situation, you will have to pay the full cost (rather than paying just your co-insurance or co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a
Coordination of Benefits/Direct Claim form
.
Send your claim along with your receipt(s) to:
Medco Health Solutions, Inc.
P.O. Box 14718
Lexington, KY 40512
Transition Policy
New members to our AlohaCare Advantage Plus plan may be taking drugs that are not on our formulary or that are subject to certain restrictions, such as prior authorization or step therapy. Current members also may be affected by changes in 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. Please contact AlohaCare Advantage Plus Customer Service if your drug is not on our formulary, is subject to certain restrictions, such as prior authorization or step therapy, or will no longer be on our formulary next year and you need help switching to a different drug that we cover or requesting a formulary exception.
During the period of time when you are talking with your doctor to determine the right course of action, AlohaCare Advantage Plus will provide a temporary supply of the non-formulary drug if you need a refill for the drug during the first 90 days of new membership in AlohaCare Advantage Plus. If you are a current member affected by a formulary change from one year to the next, AlohaCare Advantage Plus 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”), AlohaCare Advantage Plus will cover a 30-day supply (unless the prescription is written for fewer days). After AlohaCare Advantage Plus covers the temporary 30-day supply; generally, we will not pay for these drugs as part of our transition policy again.
AlohaCare Advantage Plus 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 a new member is a resident of a long-term-care facility (like a nursing home), AlohaCare Advantage Plus will cover a temporary 31-day transition supply (unless the prescription is written for fewer days). If necessary, AlohaCare Advantage Plus will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our Plan. If the resident has been enrolled in AlohaCare Advantage Plus for more than 90 days and needs 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 the new member pursues a formulary exception.
Transition policy for level of care changes
AlohaCare Advantage Plus, 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 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.
AlohaCare Advantage Plus 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 an exception to the AlohaCare Advantage Plus Formulary?
You, your prescribing doctor, or someone you name, may ask AlohaCare Advantage Plus to make an exception to our Part D coverage rules in a number of situations.
- You may ask us to cover your Part D drug even if it is not on our formulary. Excluded drugs cannot be covered by a Part D plan.
- You may ask us to waive coverage restrictions or limits on your Part D drug. For example, for certain Part D drugs, we limit the amount of the drug that we will cover. If your Part D drug has a quantity limit, you may ask us to waive the limit and cover more.
- You may ask us to provide a higher level of coverage for your Part D drug. If your Part D drug is contained in our Brand/Tier 2 tier, you may ask us to cover it at the cost-sharing amount that applies to drugs in the Generic/Tier 1 tier instead. This would lower the co-insurance/co-payment amount you must pay for your Part D drug. Please note, if we grant your request to cover a Part D drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Generally, we will only approve your request for an exception if the alternative Part D drugs included on the formulary or the Part D drug in the preferred tier would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
If your doctor is requesting an exception, he/she can submit the request in writing or by completing the
Medicare Part D Coverage Determination Request Form. Your doctor should submit additional information, such as medical records, to help us make a decision. The request can be submitted by mail or fax to:
AlohaCare Advantage Plus
Customer Service
1357 Kapiolani Blvd. Suite 1250
Honolulu, HI 96814
Fax #: (808) 973-0726
You can also verbally request an expedited or standard exception by calling our Customer Service Department at 973-6395 or toll-free at 1-866-973-6395 from Oahu, Neighbor Islands or Mainland.
If we approve your exception request, our approval is valid for the remainder of the plan year, so long as your doctor continues to prescribe the Part D drug for you and it continues to be safe for treating your condition. If we deny your exception request, you may appeal our decision.
Note: If we approve your exception request for a Part D non-formulary drug, you cannot request an exception to the co-payment or co-insurance amount we require you to pay for the drug.
What if my request for an exception is not approved (denied)?
You may ask AlohaCare Advantage Plus to review our initial determination, even if only part of our decision is not what you requested. An appeal to the plan about a Part D drug is also called a plan "re-determination." When we receive your request to review the initial determination, we give the request to clinical personnel in our organization who were not involved in making the initial determination. This helps ensure that we will give your request a fresh look.
If your health requires a quick response, you may ask for an “expedited appeal.” If we are using the expedited deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it.
You may request an expedited or standard re-determination in writing or by completing a
Medicare Redetermination Request Form. Mail or fax the request to:
AlohaCare Advantage Plus
Customer Service
1357 Kapiolani Blvd. Suite 1250
Honolulu, HI 96814
Fax #: (808) 973-0726
You may also verbally request an expedited or standard re-determination by calling our Customer Service Department at 973-6395 or toll-free at 1-866-973-6395 from Oahu, Neighbor Islands or Mainland.
What if my "re-determination" 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. 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 AlohaCare Advantage Plus.
MAXIMUS
Part D QIC
50 Square Drive
Victor, New York 14564
Phone #: (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. AlohaCare Advantage Plus conducts 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 AlohaCare Advantage Plus identifies a medication problem during our drug utilization review, we will work with your doctor to correct the problem.
Medication Therapy Management Programs (MTMP)
AlohaCare Advantage Plus offers Medication Therapy Management programs at no additional cost to members who have multiple medical conditions, who are taking many prescription drugs, and who have high drug costs. These programs were developed for us by a team of pharmacists and doctors. We use these medication therapy management programs to help us provide better coverage for our members. For example, these programs help us make sure that our members are using appropriate drugs to treat their medical conditions and help us identify possible medication errors. AlohaCare Advantage Plus may contact members who qualify for these programs. If we contact you, we hope you will join so that we can help you manage your medications. Remember, you don’t need to pay anything extra to participate. If you are selected to join a medication therapy management program we will send you information about the specific program, including information about how to access the program. Medicare Therapy Management Programs are not plan benefits of AlohaCare Advantage Plus.
What if I have a complaint about the Prescription Drug Plan?
A complaint is called a "grievance." A grievance is any complaint, other than one that involves a request for an initial determination or an appeal. Grievances do not involve problems related to approving or paying for Part D drugs, Part C medical care or services, problems about having to leave the hospital too soon, and problems about having Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF) services ending too soon.
Some examples of why you might file a grievance include:
- Problems with the service you receive from Customer Service;
- Waiting too long for prescriptions to be filled; or
- Problems getting appointments when you need them, or waiting too long for them.
To file a grievance, you may call AlohaCare Advantage Plus Customer Service Department at 973-6395 from Oahu or toll-free at 1-866-973-6395 from Oahu, Neighbor Islands or Mainland, 8 a.m. to 8 p.m., Monday through Friday or you can visit us Monday through Friday, 8 a.m. to 5 p.m. TTY/TDD users should call 1-877-477-5990.
You also may contact us in writing at the following address:
AlohaCare Advantage Plus
Grievance and Appeals Department
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
Phone #: (808) 545-2550
Toll-free: 1-800-525-6550
Fax #: (808) 440-6030
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 Oahu, Neighbor Islands or Mainland, 8 a.m. to 8 p.m., Monday through Friday or you can visit us Monday through Friday, 8 a.m. to 5 p.m. TTY/TDD 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
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 Oahu, Neighbor Islands or Mainland, 8 a.m. to 8 p.m., Monday through Friday or you can visit us Monday through Friday, 8 a.m. to 5 p.m. TTY/TDD 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
For more information, look at
Chapter 9 in your Evidence of Coverage (EOC) booklet.
Grievances and Appeals Data
AlohaCare Advantage Plus will track and maintain records about the receipt and handling of organization or coverage determinations (including exceptions), appeals and grievances. We will also disclose organization and coverage determination (including exceptions), appeals and grievances data to you upon request. To obtain this data, you should call AlohaCare Advantage Plus Customer Service at 973-6395 on Oahu, or toll free at 1-866-973-6395 from Oahu, Neighbor Islands or the Mainland, 8 a.m. to 8 p.m., Monday through Friday or you can visit us Monday through Friday, 8 a.m. to 5 p.m. TTY/TDD users should call 1-877-477-5990.
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. Here are some fact sheets you might find helpful:
Contact Us
AlohaCare is a health plan with a Medicare contract with the Federal government. If you have any questions or for additional network pharmacy information, call AlohaCare Advantage Plus Customer Service from Oahu at 973-6395 or toll-free at 1-866-973-6395 from Oahu, Neighbor Islands or Mainland, 8 a.m. to 8 p.m., Monday through Friday, or visit us 8 a.m. to 5 p.m., Monday through Friday. (TTY/TDD users can call 1-877-447-5990.) Our office is located at 1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814.