Prescription Drugs
Important Notice IngenioRx will change its name to CarelonRx starting January 1, 2023. The name change will not affect your benefits or how you fill your prescriptions. Please be aware of the following: - If you fill a prescription at our home delivery or specialty pharmacies, your prescription bottle label will include the new CarelonRx name beginning January 1, 2023.
- You will not need new prescriptions for any existing prescriptions.
- Starting on January 1, 2023, use your current login and password at our new website found at carelonrx.com. There is no need to re-register.
|
Your Pharmacy Rx Drug Benefit for 2022
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: |
| Deductible: | $0 |
| Generic: | $0 or $1.35 or $3.95* |
| For all other drugs: | $0 or $4.00 or $9.85* |
* All cost sharing is based on your level of Medicaid eligibility. Contact Medicaid for details.
Your Pharmacy Rx Drug Benefit for 2023
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.
Important Benefit Information for Enrollees who Qualify for "Extra Help":
If you receive "Extra Help" to pay for your Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance, you may be eligible for other targeted supplemental benefits and/or target reduced cost sharing. For all covered Part D drugs, AlohaCare Advantage Plus members pay $0 copay.
| Full Amount | With Extra Help from Medicare, depending upon your income and institutional status, you pay: |
| Deductible: | $0 |
| Generic: | $0 |
| For all other drugs: | $0 |
Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information.
Important Message About What You Pay for Insulin - You won’t pay more than $0 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on.
If you have limited income and resources, you may be able to get Extra Help. Because you are eligible for QUEST Integration (Hawai`i 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 Administration 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 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.
You can search our
Drug Finder to find the drugs that you can use.
The formulary is a list of covered drugs selected by AlohaCare Advantage in consultation with a team of health care providers and 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.
AlohaCare allows members to receive up to a 100-day supply of certain generic medicines such as for:
• blood pressure;
• diabetes; and
• cholesterol.
You can search our Drug Finderʻs AlohaCare Advantage Plus (HMO SNP) "PDF" to find drugs eligible for this extended supply.
The Food and Drug Administration (FDA) ensures that a drug is safe and effective before it is available on the market. The FDA can recall a drug so it is not available.
A recall can happen when a drug is found to be either defective or could be harmful for use.
There are 3 types of recalls required by the FDA. The type of recall is based on the level of danger involved:
• Class I: Dangerous or defective products that could cause serious health problems or death. Example: A label mixed up on a lifesaving drug.
• Class II: Products that might cause a short-term health problem or pose only a slight threat of a serious nature. Example: A drug that is under-strength but is not used to treat life-threatening illness.
• Class IIII: Products that may not cause any bad health reactions, but violate FDA labeling or manufacturing laws. Example: A minor pill bottle defect.
Drug companies may also decide to remove a drug or product for other reasons. This is called withdrawal. Example: A drug is removed from the market due to tampering.
The AlohaCare Pharmacy Department will tell members, doctors, and pharmacies when there is a Class I or Class II drug recall. We also inform our members in writing when drugs are withdrawn from the market for safety reasons.
Talk with your doctor or pharmacist about drug recalls and withdrawals that may affect you.
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.
- 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.
- 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 facility, 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 fills may apply to members with level of care changes at point of sale.
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 program is offered through our partnership with IngenioRx, CVS Caremark and OutcomesMTM. 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)
- Diabetes
- Dyslipidemia
- Hypertension
- Rheumatoid Arthritis (RA)0
- You take 8 or more chronic maintenance medicines covered by Medicare Part D
- You spend $4,696 or more per year in 2022 on Part D covered medications
Additionally, members that are enrolled in their Health Plan's Drug Management Program(s) may be auto-enrolled in the MTM program.
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 (CMR) 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 and/or phone call that tells you how to get started.
- Comprehensive Medication Review (CMR))
- You will have the chance to review your medicines with a highly-trained pharmacist or other health professional. The CMR typically takes about 15-30 minutes, depending on your needs. During this call any issues with your medicines will be discussed.
- The CMR can be scheduled at a convenient time for you.
- The CMR may also be provided in person at your provider’s office, pharmacy, or long-term care facility.
- After you complete the CMR, a summary is mailed to you. The summary includes a medication action plan (MAP) with space for you to take notes or write down any follow-up questions.
- You also will be mailed a personal medication list (PML) that lists all of the medicines that you take and the reasons why you take them.
- We encourage you to share the CMR summary materials with your doctor(s).
- Click here to see an example of the CMR letter.
- Ongoing targeted medication reviews (TMR)
- At least once every 3 months, your medicines will be reviewed.
- If a potential problem is detected, you or your doctor(s) may be contacted by telephone or mail to review.
For information about the MTM Program or to see if you qualify, you can call AlohaCare Member Services at 808-973-6935 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.
AlohaCare wants you to have every opportunity to participate in this program when and where convenient for you. That is why we work with IngenioRx and other health organizations to provide MTM services on our behalf. One of these organizations may contact you about completing a Comprehensive Medication Review (CMR) or other MTM services.
Partner organizations: IngenioRx Clinical Pharmacy Care Center - (1-833-404-2161), OutcomesMTM - Patient Engagement Team
*Additional partner organizations may be added if they meet our rigorous requirements to services our members.
AlohaCare has a network of pharmacies that can fill your medicines.
Pharmacy Finder
To find out if a pharmacy works with AlohaCare, use our
online Provider Finder. By clicking on this link, you will be leaving the AlohaCare website. Or you can download the Provider Directory found on the
Member Documents page.
We understand that going to the pharmacy can be hard sometimes. AlohaCare is offering the convenience of home delivery of your medicine. With IngenioRx Home Delivery, you can request for drugs you take on a regular basis be delivered to your home. These include drugs that you take every day to treat your condition, such as diabetes, high blood pressure, or asthma.
Ask your doctor if your drug can be filled by IngenioRx Home Delivery. To sign up for home delivery, please mail in the IngenioRx Home Delivery Mail Service Order Form found on the
Member Documents page. If you need help with your Home Delivery drugs, call IngenioRx Home Delivery Pharmacy toll free at 833-514-1300. You can also call
Customer Service.
H5969_WEB40062301