AlohaCare now covers a 100-day supply for maintenance medications for Medicare.
Please send a new prescription written for a 100-day supply of maintenance medications to your patient's pharmacy to help improve your member's medication adherence and decrease trips to the pharmacy for refills.
AlohaCare Advantage Plus (SNP) Formulary
AlohaCare covers all medically necessary Medicare Part D medications. We use a Formulary, which is a list of the drugs that we prefer our providers to prescribe. AlohaCare also covers the over-the-counter drugs listed on our Formulary. Your patient will need a prescription for an over-the-counter drug to be covered by AlohaCare.
You can search our Drug Finder
to find drugs that are on our Formulary.
Some drugs require a coverage determination to explain to us why a specific medication or a certain amount of a medication is needed. An exception for drug coverage can also be requested. We must approve the request before the member can get the medication.
For more details about covered and non-covered drugs, please see the introductory pages to our Formulary PDF document in our Drug Finder
Prescribers can submit a Prescription Drug Prior Authorization Request Form or Physician Administered Drug Request Form that can be found under Pharmacy Forms on the Provider Forms
Alternatively, prescribers can send requests using their current electronic health record/electronic medical record (EHR/EMR) system or submit a Prescription Drug Prior Authorization Request Form or Physician Administered Drug Request Form that can be found under Pharmacy Forms on the Provider Forms page.
For our member’s convenience and to encourage medication adherence, we cover up to a 100-day supply of maintenance medications. You can search our Drug Finder
to find drugs eligible for this extended supply.
See below for a summary of drug recalls and withdrawals:
New members enrolling in AlohaCare Advantage Plus may be taking drugs that are not on our Formulary or that are subject to certain restrictions. Current members may also be affected by changes to our Formulary from one year to the next.
- During the first 90 days of new member enrollment, we will cover a one-time temporary 30-day transition supply of a Part D non-formulary drug or a Part D drug that has coverage restrictions.
- During the first 90 days of a new plan year, we will cover a one-time temporary 30-day transition supply for existing users of a Part D non-formulary drug or a Part D drug that has coverage restrictions.
- For residents 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 fills may apply to members with level of care changes at point of sale.
Please consider switching to a preferred alternative on our Formulary, but if that is not clinically appropriate, please submit a coverage determination or exception request.
Pharmacy Billing Information
BIN: 610014 | PCN: MEDDPRIME |GROUP: ALOHACARE
For coordination of benefits (COB) billing of Medicare Part B claims (e.g. diabetic testing supplies and nebulizer drugs), bill Medicare plan (AlohaCare member ID starts with MEM) as primary plan and QUEST plan (AlohaCare member ID starts with zeroes) as secondary plan.
For members with Medicare and Medicaid with AlohaCare, some over-the-counter (OTC) drugs are covered under the member’s QUEST Integration benefit. Please submit these claims using the member’s QUEST plan as primary plan instead of Medicare.
For questions about pharmacy processing and claim overrides, contact AlohaCare Customer Service
AlohaCare covers partial fills to synchronize medication refills to the same day each month. This only applies to maintenance medications that are normally covered for the member (the medication is on the formulary without restrictions or the member has an active prior authorization).
For refill date synchronization, the pharmacy should calculate the days’ supply needed in a partial fill so that future fills of maintenance medications will fall on the same day.
- For Medicare members, a daily cost-sharing rate will be applied for a prorated copayment based on the days’ supply dispensed for each medication.
- For all AlohaCare members, if a claims reject with NCPDP Reject Code 79 (Refill Too Soon), the pharmacy may override the reject with either Submission Clarification Code (SCC) 47 (Shortened Days’ Supply Fill) or SCC 48 (Fill Subsequent to a Shortened Days’ Supply Fill). QUEST claims will also return a secondary message of “RX ELIGIBLE FOR SYNCHRONIZATION. IF NEEDED, SHORTEN DS AND RESUBMIT WITH SCC 47 OR 48.”
To find out if a pharmacy works with AlohaCare, use our online Provider Finder or download the Provider Directory found on the Member Documents page.
Pharmacy Clinical Programs and Services
With mail order, members have the convenience of getting up to a 100-day supply of maintenance medications delivered directly to their home. Members can register for mail order at www.Express-scripts.com/StartHD
. Once ordered, medications should be delivered to the member in about 8 days (refills) to 14 days (new prescriptions). There is no charge for standard shipping.
To send 100-day supply electronic prescriptions for mail order, select Express Scripts Pharmacy in your ePrescribing platform or call 1-855-778-1445.
AlohaCare Advantage Plus members with complex health needs may qualify for our Medication Therapy Management (MTM) program. The MTM program is required by the Centers for Medicare and Medicaid Services (CMS) as a patient centric and comprehensive approach to improve medication use, reduce the risk of adverse events, and improve medication adherence. AlohaCare and Express Scripts has partnered with Tabula Rasa HealthCare, MedwiseRx, to perform all MTM services.
Members will receive a letter to voluntarily enroll in the MTM program if they meet ALL of the following criteria:
1. Have at least 3 of the following conditions or diseases:
- Chronic heart failure (CHF)
- End-stage renal disease (ESRD)
- Chronic Obstructive Pulmonary Disease (COPD), AND
2. Take at least 8 covered Part D medications, AND
3. Are likely to have medication costs of covered Part D medications greater than $4,376 per year.
To help reduce the risk of possible medication problems, the MTM program offers two types of clinical review of a member’s medications:
- Targeted Medication Review (TMR): At least quarterly, we will review all prescription medications and contact the member/caregiver, the pharmacist, and/or the prescriber if we detect a potential problem.
- Comprehensive Medication Review (CMR): At least once per year, a pharmacist or other health professional with conduct a medication profile review and offer a free discussion with the member to help members use their medications safely. This CMR is provided to members confidentially via telephone by pharmacies operated by Tabula Rasa HealthCare. The CMR may also be provided in person or via telehealth at the provider’s office, pharmacy, or long-term care facility. If members or their caregivers are not able to participate in the CMR, this review may be completed directly with the provider. These services are provided on behalf of AlohaCare. This review requires about 30 minutes. Following the review, a written summary will be sent, which includes:
- Medication Action Plan (MAP): The action plan has steps members should take to help get the best results from their medications.
- Personal Medication List (PML): The medication list will help keep track of a member’s medications and how to use them the right way.
Quality is important to AlohaCare. Regular use of medications for hypertension, diabetes, and cholesterol help keep these disease states under control and prevent secondary health complications for our members. As a result, we strive to improve our Centers for Medicare & Medicaid Services (CMS) Star measures for medication adherence and statin use in persons with diabetes.
Medication Adherence Strategies:
- Prescribe at 100-day supplies of medications for hypertension, diabetes, and cholesterol to decrease the number of trips to the pharmacy for refills.
- Hypertension medications such as angiotensin converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), and direct renin inhibitors.
- Diabetes medications such as biguanides, sulfonylureas, thiazolidinediones, dipeptidyl peptidase 4 (DPP-4) inhibitors, incretin mimetics, meglitinides, and sodium-glucose transport protein-2 (SGLT-2) inhibitors.
- Cholesterol medications such as statins (atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, or simvastatin) and statin combinations.
- Encourage mail order or home delivery for patients who have transportation issues. Contact AlohaCare for a list of pharmacies that may offer free delivery to the member’s home or repackage medications to improve adherence.
- Educate patients about the importance of taking their medication(s) at the same time each day. Encourage use of alarms, pill boxes, and/or incorporating taking medicine with a set routine like after brushing teeth.
Statin use in those with Diabetes: Diabetic patients are at a high risk for cardiovascular disease and evidence supports the use of statin therapy in persons with diabetes who are between 40 and 75 years old. For patients taking diabetes medications, please consider adding a 100-day supply of a statin for those not already on statin therapy.
General Resources & Contact Information
Contact AlohaCare Provider Customer Service