AlohaCare was organized in 1994 through the efforts of the Community Health Centers in Hawaii to ensure that the needs of Hawaii’s under-served populations would continue to be met under the State’s progressive initiative to enroll Medicaid recipients into managed care (the Hawaii QUEST program).
AlohaCare is Hawaii’s only non-profit health plan that serves QUEST and Medicare members exclusively.
The QUEST Story
QUEST stands for Quality care, ensuring Universal access, encouraging Efficient utilization, Stabilizing costs, and Transforming the way health care is provided to public clients.
AlohaCare helps the people of Hawaii achieve optimal health through high quality and cost effective health care, education, and community service. This is accomplished with an emphasis on prevention, primary care, and community-governed health centers in collaboration and partnership with health care providers.
At AlohaCare, we are dedicated to providing the most efficient and cost-effective services available to our provider partners, as well as our members.
AlohaCare QUEST recognizes that drug formularies are an ever growing part of the health care management system. Therefore, AlohaCare QUEST has developed a generic-based formulary to balance health care needs and provide cost effective care.
AlohaCare QUEST employs various strategies to control rising prescription drug costs, including:
- Drug formularies
- Use of generics whenever available
- Prior Authorization
- Quantity Limits on drug claims and supply amounts
- Step-therapy rules on drug claims
- Concurrent drug utilization review edits at the retail pharmacy level
The AlohaCare QUEST Formulary
The AlohaCare QUEST formulary was developed as the cornerstone of AlohaCare’s Pharmacy program. It is a compilation of selected medications that allow health care providers to offer the most cost-effective drug therapy options possible in today’s environment of increasing drug prices.
Choosing an appropriate formulary drug can help our members, your patients, take full advantage of their AlohaCare QUEST prescription drug benefits in which they will be able to gain access to medications they require to stay healthy.
The AlohaCare’s QUEST Pharmacy and Therapeutics Committee (P&T) is involved in the development and maintenance of the formulary. The AlohaCare QUEST P&T Committee is an independent advisory committee comprised of physicians, pharmacists, and nurses. The committee offers a forum to providers for input on medical efficacy and therapeutic benefit of drug therapies, diagnostic technologies, and alternative treatment interventions. On a quarterly basis, the AlohaCare QUEST P&T Committee reviews new and existing medications to ensure that the AlohaCare formulary remains responsive to the ever changing needs of our members and providers.
All recommendations from the P&T Committee are reviewed by AlohaCare’s Clinical and Quality Improvement Advisory Committee (QIAC). The QIAC is responsible for assessing the status and progress of all quality improvement efforts. The QIAC is responsible for recommending and/or monitoring the implementation of corrective action plans. The QIAC reviews outcome studies and recommends action based upon results. The QIAC also makes recommendations regarding the AlohaCare QUEST formulary and use of diagnostic and treatment technologies.
Product Selection Criteria
The AlohaCare P&T Committee considers clinical information on new-to-market drugs, both brands and generics that are within covered therapeutic categories. The evaluation includes all or part of the following:
- Patient administration/compliance considerations
- Comparative cost benefit analysis
Formulary Subject to Change
Generally, the AlohaCare QUEST P&T Committee reviews the formulary regularly to ensure its continued effectiveness and is updated monthly. There are some brand name drugs listed on the AlohaCare QUEST formulary that do not have a generic counterpart. Once a generic becomes available, the brand product will be removed from the formulary and will be replaced with its generic equivalent.
If we remove a drug from our formulary we must notify the providers and the affected members of the removal at least 30 days prior to the effective change. If the Food and Drug Administration deems a drug on our formulary to be unsafe or a drug manufacturer removes the drug from the market, we will remove the drug from our formulary immediately and provide notice to the providers, as well as members who currently are taking the medication.
Covered drugs are limited to those listed on the AlohaCare QUEST formulary and are limited to a 30 day supply at one time. All non-formulary and some formulary drugs, require prior authorization. Brand name drugs, with a generic counterpart, require prior authorization. In addition, prior authorization is required for early refills for vacation supply, changes in dosage, and other “refill too soon” situations.
The following are exclusions and are not covered by the QUEST pharmacy benefit:
- Drugs not approved by the U.S. Food and Drug Administration or deemed “less than effective” (DESI 5 and 6) by Centers for Medicare & Medicaid Services (CMS)
- Drugs prescribed by a dentist that are not primarily medical in nature (dental coverage is provided by the Medicaid fee-for-service program)
- Experimental and investigational drugs that are generally an unproven benefit
- Drugs related to gender reassignment
- Hansen’s Disease drug treatment
- Drugs related to in-vitro fertilization, reversal of sterilization, artificial insemination and to test fertility
- Drugs related to food supplements and prepared formulas
- Immunizations for travel (domestic or foreign)
- Pulmonary tuberculosis treatment, when treatment is available at no charge to the general public
- Drugs excluded by the Hawaii Medicaid Program
- Sexual dysfunction drug treatments
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
- Prior Authorization: AlohaCare QUEST requires a prior authorization for select drugs. These drugs are generally those that have a high side effect potential, those that should be reserved for specific FDA indications, or those that have a high misuse or abuse potential. This means that an approval is needed from AlohaCare QUEST before these drugs can be filled at a participating retail pharmacy and covered by AlohaCare. If an approval is not obtained, members may experience a delay in accessing drugs at a participating retail pharmacy.
- Quantity Limits: In order to minimize the potential for adverse drug reactions due to over utilization, AlohaCare QUEST has implemented a dispensing limit on select medications. These quantities were determined based on the FDA dosing recommendations. If it is determined that it is medically necessary for an AlohaCare QUEST member to take a larger amount, a request to make an exception to this restriction can be made. To find out if a drug has a quantity limit, you may call AlohaCare’s Pharmacy Management at (808) 973-7418 or Toll-free at 1-866-973-7418.
- Step Therapy: In some cases, certain drugs to treat a medical condition should be tried first before AlohaCare QUEST will cover another drug for that condition. For example, if Drug A and Drug B both treat a medical condition, AlohaCare QUEST may not cover drug B unless Drug A is tried first. If Drug A does not work, AlohaCare QUEST will then consider coverage of Drug B.
These drugs with restrictions or limits are indicated in the QUEST formulary with a PA (Prior Authorization), QL (Quantity Limit) or ST (Step Therapy) following its drug name.
You may ask AlohaCare QUEST to make an exception to these restrictions or limits.
Request additions / deletions to the Formulary
If you are a provider and would like to request a drug addition to or deletion from the AlohaCare QUEST Formulary, you need to complete an AlohaCare Request for Addition /Deletion of Medication to Formulary form, which will be reviewed by the AlohaCare P&T Committee. To request an electronic copy of this form, please call AlohaCare’s Pharmacy Management at (808) 973-7418 or Toll-free at 1-866-973-7418.
Request for an exception to the AlohaCare QUEST Formulary
Providers may ask AlohaCare QUEST to make an exception to our coverage rules. The following are types of exceptions that you may ask us to make:
- You may request that we make an exception to cover a drug that is not listed on the AlohaCare QUEST Formulary.
- You may request that we make an exception and reconsider coverage restrictions or limits on a drug. For example, for certain drugs, AlohaCare QUEST limits the amount of the drug that we will cover. If a drug has a quantity limit, you may request that we make an exception and reconsider the limit and cover more if needed.
Generally, AlohaCare QUEST will only approve your request for an exception if the drugs included on the plan’s formulary have been shown to be less effective in treating a patient’s condition or would cause an adverse medical effect to a patient.
Providers should contact us for an initial coverage decision on a QUEST Formulary or utilization restriction exception by completing the AlohaCare Drug Coverage Request Form. Completed forms should be faxed to Pharmacy Management at (808) 973-6327 or Toll-free at 1-888-667-0680.
When requesting a formulary or utilization restriction exception, you should submit a statement supporting your request on the Drug Coverage Request Form or as an attachment. In general, a decision will be made within (7) business days unless we require additional information from you.
Request a copy of the AlohaCare QUEST Formulary
The AlohaCare QUEST Formulary is one of many valuable tools available to you to ensure that our members receive the highest quality of care in a cost-effective manner
To request a copy of the AlohaCare QUEST Formulary or for more detailed information about the AlohaCare QUEST benefits, please call Provider Relations at (808) 973-1650 or 1-800-434-1002.
For more information
If you have questions about AlohaCare QUEST prescription drug coverage, please call AlohaCare’s Pharmacy Management at (808) 973-7418 or Toll-free at 1-866 973-7418.