Your Rx Drug Benefit for 2020
As a member of AlohaCare Advantage Plus (HMO SNP), you are automatically qualified for "Extra Help" to pay for your prescription drug costs. This is also called "Low Income Subsidy" or LIS.
|Full Amount||With Extra Help from Medicare, depending upon your income and institutional status, you pay:|
|Generic:||$0 or $1.30 or $3.60*|
|For all other drugs:||$0 or $3.90 or $8.95*|
* All cost sharing is based on your level of Medicaid eligibility. Contact Medicaid for details.
If you have limited income and resources, you may be able to get Extra Help. Because you are eligible for QUEST Integration (Medicaid), you qualify for and are getting "Extra Help" from Medicare to pay for your prescription drug plan costs. You do not need to do anything further to get this "Extra Help." Extra Help may pay for your monthly premium, yearly deductible, prescription coinsurance and copayments. 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.
With "Extra Help", Medicare pays for your prescription drug plan costs. The Medicare Coverage Gap Discount Program does not apply to you. You already have coverage for your prescription drugs during the coverage gap through the "Extra Help" program. Please see Chapter 6 of the Evidence of Coverage that explains the various stages of drug coverage If you have questions about "Extra Help," call:
- 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7 days a week;
- The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call, 1-800-325-0778; or
- Your State Medicaid Office.
The Medication Therapy Management (MTM) program is a service for members with multiple health conditions and who take multiple medicines. The MTM program helps you and your doctor make sure that your medicines are working to improve your health.
To qualify for the MTM program, you must be eligible. Please see below for those details. If you qualify, you will be auto-enrolled into the program and the service is provided at no additional cost to you. You may choose not to participate in the program, but it is recommended that you make use of this free service.
The MTM is offered through our partnership with SinfoniaRx. The MTM program is not considered a part of the plan's benefit.
You may qualify for the MTM Program if:
- You have 3 or more chronic health problems. These may include:
- Chronic Heart Failure (CHF)
- Chronic Obstructive Pulmonary Disease (COPD)
- End-Stage Renal Disease (ESRD)
- You take 8 or more chronic maintenance medicines covered by Medicare Part D
- You spend $4,255 or more per year on Part D covered medications
If you qualify for the MTM Program, you will be contacted and have the chance to speak with a highly-trained pharmacist or other health professional. During that call, the pharmacist or other health professional will complete a comprehensive medication review of your medicines and talk with you about:
- Any questions or concerns about your prescription or over-the-counter medicines, such as drug safety and cost
- Better understanding your medicines and how to take them
- How to get the most benefit from your medicines
If you qualify for the MTM Program, you will receive:
- Welcome letter that tells you how to get started.
- Comprehensive medication review
- You will have the chance to review your medicines with a highly-trained pharmacist or other health professional. This review will take about 20-40 minutes. During this call any issues with your medicines will be discussed. The call can be scheduled at a convenient time for you.
- The review may also be provided in person at your provider’s office, pharmacy, or long-term care facility. If you or your caregiver is not able to participate, this review may be completed directly with your provider.
- After you complete the comprehensive medication review, a summary is mailed to you. The summary includes a medication action plan with space for you to take notes or write down any follow-up questions.
- You also will be mailed a personal medication list that lists all of the medicines that you take and the reasons why you take them.
- Click here to see an example of the comprehensive medication review letter.
- Ongoing targeted medication reviews
- At least once every 3 months, your medicines will be reviewed.
- If a potential problem is detected, you will be contacted by telephone or mail and/or your doctor will be contacted.
For information about the MTM Program or to see if you qualify, you can call AlohaCare Member Services at 973-6935 or toll-free at 1-866-973-6395; October 1 to March 31, 8 a.m. to 8 p.m., 7 days a week; April 1 to September 30, 8 a.m. to 8 p.m., Monday through Friday. TTY/TDD users call 1-877-447-5990.
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, the prescription is filled at a network pharmacy, and other coverage rules are followed. We may add or remove drugs from our formulary during the year.
A formulary is a list of covered drugs selected by AlohaCare Advantage in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program.
Some covered drugs may have additional requirements or limits on coverage. These limitations are marked next to each drug on the formulary with "BvsD," "LA," "PA," "QL" or "ST."
- Part B versus D (BvsD): This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
- Limited Access (LA): This prescription may be available only at certain pharmacies. For more information, please call AlohaCare Member Services.
- Prior Authorization (PA): AlohaCare Advantage Plus requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptin. If you do not get approval, we may not cover the drug.
- Quantity Limit (QL): For certain drugs, AlohaCare Advantage Plus limits the amount of the drug that we will cover.
- 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.
If you are a new member of AlohaCare Advantage Plus, you may be taking drugs that are not on our Formulary or that are subject to certain restrictions. Or, you may be a current member and are affected by changes to 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.
- One-time temporary 30-day supply of the non-formulary drug if you need a fill for the drug during the first 90 days of your membership.
- One-time temporary 30-day supply of the non-formulary drug if you need a fill for the drug during the first 90 days of the new plan year.
- For drugs that are not on our formulary, or that have coverage restrictions or limits (but is otherwise considered a “Part D drug”), we will cover a 30-day supply.
- If you are a new member and are a resident of a long-term-care (LTC) facility (like a nursing home), we will cover a temporary 91 to 98-day transition supply (unless the prescription is written for fewer days). After the transition period has expired for residents of a LTC, our policy provides up to a 31 day emergency supply of non-formulary Part D drugs while an exception or prior authorization is requested.
- Transition fill may apply to members with level of care changes at point of sale.