Prescription Drugs
Your Rx Drug Benefit for 2018
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 $1.25 or $3.35* |
For all other drugs: | $0 or $3.70 or $8.35* |
* 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. The
2018 Low Income Premium Table show you what your monthly plan premium will be with extra help.
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.
Medication Therapy Management (MTM) programs are available to you at no additional cost if you have multiple medical conditions, taking many prescription drugs, and have high drug costs.
If you have at least three chronic diseases or are taking at least seven different drugs or spend $3,967 or more per year on Part D covered medications, you are eligible for the MTM program. The following chronic diseases apply:
- Asthma
- Chronic Heart Failure (CHF)
- Chronic Obstructive Pulmonary Disease (COPD)
- Depression
- Diabetes
- End-Stage Renal Disease (ESRD)
- High blood fat levels
- High blood pressure
- Osteoporosis
AlohaCare Advantage Plus contracts with Express Scripts, the AlohaCare Pharmacy Benefit Manager, to provide this free program to you. This program gives you access to the personal services of an Express Scripts pharmacist who can help look out for your health and safety. In addition, an Express Scripts Medicare Advisor is available to ensure you get the most value from your benefit plan. Though, our programs are not considered a plan benefit, these MTM programs help us provide better coverage for our members.
For information about the MTM Program or to see if you qualify, you can call our Member Services at 1-866-973-6395, 8 a.m. to 8 p.m., 7 days a week. 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.
2018 Comprehensive Formulary (updated 06/2018)
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.
- 2018 Transition Policy
- 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.
H5969_400620_18 Approved