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 and the prescription is filled at a network pharmacy. See below for information on restrictions and limitations. We may add or remove drugs from our formulary during the year. We will provide updates when the formulary changes.
For more information, click here. The formulary will tell you about:
- The drugs included in our formulary
- Quantity limits for drugs
- Restrictions that apply to drugs such as prior authorization requirements
- How to obtain prior authorization for a drug, if required
- How your physician may request an exception to our formulary, including the documentation that we require to review this request
- How you or your physician may appeal our decision not to approve the request for an exception
- The process for generic substitution of drugs
- Step therapy requirements
- Therapeutic interchange requirements
- Any other requirements, restrictions, limitations, or incentives that apply to the use of certain drugs
What is the difference between a brand name drug and generic drug?
There is little difference between a brand name drug and the generic version. Generic drugs have the same ingredients as brand name drugs. They are usually a different color and shape. Generic drugs are not as expensive as brand name drugs. Your pharmacy will fill your prescription with a generic drug if it is available. Generic medications are as safe and effective as their brand name drugs.
How does AlohaCare decide what prescription drugs are covered?
AlohaCare has a committee of physicians and pharmacists that decide about our medication procedures. They review the available drugs and select the ones that they believe are the best for our members.
Are there any restrictions or limitations?
There are some limits on your drugs. Most of the time, you will get a 30 day supply unless your doctor orders a supply for a shorter period of time, based on your need for the drug (for example, antibiotics). Situations in which a drug limit may apply include:
- Approval: Your doctor may need prior approval for certain drugs.
- Quantity limits: We encourage safe use of drugs by setting a maximum amount per month for some drugs. You may not get more than the amount prescribed to you unless your doctor asks us to make an exception.
- Step therapy: In some cases, you must try Drug A before Drug B to treat your medical condition. If Drug A was not tried first, Drug B may not be covered.
- Therapeutic interchange: You may be asked to take a drug that is chemically different from the drug originally prescribed. This different drug will have the same therapeutic purpose and will be used for the same FDA approved conditions. The pharmacist or your prescriber may ask you to take this drug and will explain the reasons why he or she believes this is a better drug choice for you. You do not have to agree. If you do not agree, your original drug prescription will be filled.
How much will my drugs cost?
There is no copayment for your drugs, unless you also have Medicare. If you have Medicare, your Medicare Part D plan will cover most of your drugs though you will have a copayment. There are certain drugs and over-the-counter medications not covered by your Medicare Part D plan that AlohaCare may cover without a copayment.
What if my drug is not on AlohaCare’s list of covered drugs?
If your drug is not listed, contact your doctor. Your doctor may prescribe another drug that is similar to a drug on our drug list. Or, your doctor can ask for an exception.
Can I ask for an exception to get a drug covered?
You or your doctor can ask AlohaCare to cover a certain drug that is not on our list. You or your doctor may call to ask for an exception. We will ask your doctor for the reason why you are requesting a certain drug. We will let you and your doctor know if we approve your request.