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Formulary


The Formulary is a list of the drugs that we cover. It may change during the year. We may add or remove drugs from our formularies throughout the year. Look below for our current Formulary and formulary updates.

 
Request for an Exception to the AlohaCare QUEST Integration Formulary
Providers may ask AlohaCare QUEST Integration 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 Integration 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 Integration 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 Integration 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 Integration Formulary or utilization restriction exception by completing the AlohaCare QUEST Integration Standard PA Request FormWhen 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. 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 Additions / Deletions to the AlohaCare QUEST Integration Formulary
If you are a provider and would like to request a drug addition to or deletion from the AlohaCare QUEST Integration 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. Completed forms should be faxed to Pharmacy Management at (808) 973-6327 or toll free at 1-888-667-0680. 

 

QUEST Integration Formulary Management Procedures
 
Utilization Strategy
 
AlohaCare QUEST Integration recognizes that drug formularies are an ever growing part of the health care management system. Therefore, AlohaCare QUEST Integrationhas developed a generic-based formulary to balance health care needs and provide cost effective care.
 
AlohaCare QUEST Integration 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 Integration Formulary
 
The AlohaCare QUEST Integration 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 Integration prescription drug benefits in which they will be able to gain access to medications they require to stay healthy.
 
AlohaCare’s QUEST Integration Pharmacy and Therapeutics Committee (P&T) is involved in the development and maintenance of the formulary. The AlohaCare QUEST Integration 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 Integration 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 Integration 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:
 
 
  • Safety and Efficacy
  • Comparison studies
  • Approved indication
  • Patient administration/compliance considerations
  • Pharmacokinetics
  • Comparative cost benefit analysis
  • Adverse effects
  • Contraindications/Warnings/Precautions
 
Formulary Subject to Change
 
Generally, the AlohaCare QUEST Integration 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 Integration 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.
  
Drug Coverage
 
Covered drugs are limited to those listed on the AlohaCare QUEST Integration 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 Integration 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
 
Formulary Restrictions
 
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
 
  • Prior Authorization: AlohaCare QUEST Integration 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 Integration 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 Integration 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 Integration 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 Integration will cover another drug for that condition. For example, if Drug A and Drug B both treat a medical condition, AlohaCare QUEST Integration may not cover drug B unless Drug A is tried first. If Drug A does not work, AlohaCare QUEST Integration will then consider coverage of Drug B.
 
These drugs with restrictions or limits are indicated in the QUEST Integration formulary with a PA (Prior Authorization), QL (Quantity Limit) or ST (Step Therapy) following its drug name.
 
You may ask AlohaCare QUEST Integration to make an exception to these restrictions or limits.
 
Request a copy of the AlohaCare QUEST Integration Formulary
 
The AlohaCare QUEST Integration 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 Integration Formulary or for more detailed information about the AlohaCare QUEST Integration benefits, please call Provider Relations at (808) 973-1650 or 1-800-434-1002.
 
For more information
 
If you have questions about AlohaCare QUEST Integration prescription drug coverage, please call AlohaCare’s Pharmacy Management at (808) 973-7418 or Toll-free at 1-866 973-7418.