ALOHACARE ADVANTAGE (HMO)
While prior authorization on certain drugs and services is required for all members, our AlohaCare Advantage members are also given the following options below concerning their care. Through one of these processes, you and your patient can find out whether we cover certain services or drugs, or ask for an exception to what we cover.
An “organization determination” is our initial decision (approval or denial) about whether we will provide or cover the medical service that is requested. You are able to request an organization determination for your patient.
A “coverage determination” is a decision (approval or denial) made regarding prescription drug benefits. You can request AlohaCare to provide drug coverage for drugs that have additional restrictions or limits for your patient.
You can request AlohaCare to make an “exception” to our coverage rules. You can ask us to cover drugs not on our formulary, waive coverage restrictions or limits or provide a higher level of drug coverage of your patient.
Request forms are located under the “forms” in the provider section.