AlohaCare - Formulary (Medicare)

Formulary

AlohaCare Advantage Plus (D-SNP) Formulary

Prescription Drugs

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.

You can search our Drug Finder to find drugs that are on our Formulary.

Starting January 1, 2023, all AlohaCare members will have $0 copay for any covered drugs under the AlohaCare Advantage Plus. This includes insulin products and any Part D vaccines.

To request, add, or remove a drug from the Formulary or to change a Clinical Criteria, submit a request using the "Drug List Addition/ Clinical Criteria Request" form found under Providers – Forms – Pharmacy Forms . Requests will be presented at the next Pharmacy & Therapeutics (P&T) Committee meeting for review and consideration.

Part D-Excluded Drugs

For members with QUEST (Medicaid) benefits, certain drugs not covered by Medicare (e.g. over-the-counter products) may be covered when benefits are coordinated through the QUEST (Medicaid) plan.

Medical Injectables & Infused Drugs

For a list of drugs that AlohaCare covers under the medical benefit plan, use our Prior Auth Lookup Tool .

Maintenance Drug List

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.

Drug Recalls and Alerts

See below for a summary of drug recalls and withdrawals:

2024	2025
January 1 - March 31	January 1 - March 31
April 1 - June 30	April 1 - June 30
July 1 - September 30	July 1 - September 30
October 1 - December 31	October 1 - December 31

Please refer to the Provider Advisories page for Drug Safety Communication Alerts.

Coverage Determination & Exception Requests

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 .

Common Medicare PA Denials and Alternative Solutions/Options

Electronic prior authorization (ePA) is the preferred method for coverage determinations through the Electronic Health Record/Electronic Medical Record (EHR/EMR) system or through one of the following ePA portals:

Alternatively, prescribers can send a Medicare Prescription Drug Coverage Determination form or Physician Administered Drug Request Form that can be found under Pharmacy Forms on the Provider Forms page.

Transition Policy

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.

2026 Transition Policy

During the first 108 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 108 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 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.

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 Clinical Programs and Services

Medication Therapy Management (MTM)

AlohaCare Advantage and AlohaCare Advantage Plus (D-SNP) members with complex health needs may qualify for our Medication Therapy Management (MTM) program. The MTM program is required by The Centers for Medicare & Medicaid Services (CMS) as a patient centric and comprehensive approach to improve medication use, reduce the risk of adverse events, and improve medication adherence.

The MTM program is a service for members with multiple health conditions and 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 not considered a part of the plan's benefit.

You may qualify for the MTM Program if you meet 1 of the following 2 criteria:

On an opioid and:
1. Are using opioids with an average daily morphine milligram equivalent (MME) greater than 90mg for any time in the last 6 months and getting opioids from 3 or more prescribers and 3 or more pharmacies; OR
2. Are getting opioid prescriptions from 5 or more prescribers; OR
3. Are getting opioids from 7 or more prescribers and 7 or more pharmacies in the last 6 months; OR
4. Have had an opioid overdose diagnosis in the last 12 months and an opioid prescription claim within the last 6 months
All of the following apply:
1. Have 3 or more chronic health problems. These may include:
  - Alzheimer’s Disease
  - Bone disease-arthritis (including osteoporosis, osteoarthritis, and rheumatoid arthritis)
  - Chronic Heart Failure (CHF)
  - Diabetes
  - Dyslipidemia
  - End-Stage Renal Disease (ESRD)
  - HIV/AIDS
  - Hypertension
  - Mental health (including depression, schizophrenia, bipolar disorder, and other chronic/disabling mental health conditions)
  - Respiratory Disease (including asthma, chronic obstructive pulmonary disease (COPD), and other chronic lung disorders)
2. Take 8 or more chronic maintenance medicines covered by Medicare Part D;
3. Spend $1,623 or more in the previous 3 months on Part D covered medications.

If you qualify for the MTM Program, you will be contacted and have the chance to speak with a 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;
Understanding your medicines and how to take them; and
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)

At least once a year, we offer a free medication review with a pharmacist or other health professional to help you use your medications safely. 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, or printed during an in-person review. The summary includes a recommended To-Do List (TDL) 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 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)

Your medicines will be reviewed at least once every 3 months.
If a potential problem is detected, you, your caregiver, pharmacist, or your doctor(s) may be contacted by telephone or mail to review.

AlohaCare wants you to have every opportunity to participate in this program when and where is convenient for you. That is why we work with other health organizations and local pharmacies 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.

If you need to follow up on or to schedule a medication review you can reach us at 808-562-3061 or toll free at 1-844-269-7071, Monday through Friday, 8 a.m. to 5 p.m. HST. TTY/TDD users, please call 1-877-447-5990.

Pharmacy Star Measures: Medication Adherence & Statin Use in Persons with Diabetes or Cardiovascular Disease

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 or cardiovascular disease.

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.

Statin use in those with Cardiovascular Disease: Patients with cardiovascular disease recommended to take a moderate to high intensity statin daily to reduce cardiovascular risk in males between 21-75 years old and women between 40-75 years old regardless of LDL level. Please consider 100-day supply of statin therapy.

Mail Order & Home Delivery

With mail order, members have the convenience of getting up to a 100-day supply of maintenance medications delivered directly to their home.

OptumRx offers an option that is administered by OptumRx Home Delivery Pharmacy.

To send electronic prescriptions for home delivery/mail order select OptumRx Home Delivery Pharmacy in your ePrescribing platform. Please note that the pharmacy address will display as Overland, KS.

OptumRx Home Delivery Pharmacy Phone: 800-791-7658| Fax: 800-491-7997

Cancer Guidance Program (CGP)

Effective July 1, 2026, Optum Health will be managing prior authorization requests for selected IV/infusion chemotherapy, supportive care therapies, and therapeutic radiopharmaceuticals under the medical benefit for both QUEST (Medicaid), and AlohaCare Advantage Plus (HMO D-SNP) and AlohaCare Advantage (HMO D-SNP) members. This change is part of our ongoing commitment to streamline services and enhance support for our provider community and members.

To support the review, clinical requirements will be documented within the request submission. You can also attach medical records, if requested.

Exclusions: Members with primary insurance through another plan or drugs covered under the Pharmacy Benefit are excluded from this program.

Steps To Submit Your Request

Register for the Optum UM Platform if you haven't done so already by going to https://mbm.linkplatform.com and click on 'Self Registration for Prior Authorization'.
Sign-in directly into the Optum UM Platform and click on the Sign-In button.

Optum Registration Guide

Optum CGP User Guide

For information or questions related to oncology/radiopharmaceutical PA submission process, providers should contact Optum Health at 1-800-599-5895.

Pharmacy Network

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 Billing Information

Pharmacy Billing Information (Medicare HMO D-SNP)

AlohaCare Advantage Plus (HMO D-SNP)

AlohaCare D-SNP Medicare with AlohaCare QUEST (Medicaid) Plan

BIN: 610011| PCN: CTRXMEDD |GROUP: ALOHACARE

This plan has single transaction for coordination of benefits, which allows the member’s Medicare and QUEST (Medicaid) benefits to be coordinated automatically during the adjudication process. Members have one ID card with one BIN/PCN/GRP and one-member ID number. Single transaction for coordination of benefits will buy down Part B deductibles and cost shares to $0 after the claim is paid by Medicare. The single transaction for coordination of benefits will allow seamless coverage of OTC and non-Medicare drugs through the member’s QUEST (Medicaid) benefit.

AlohaCare Advantage (HMO D-SNP)

AlohaCare D-SNP Medicare with separate QUEST (Medicaid) Plan (from another health plan)

BIN: 610011 | PCN: CTRXMEDD |GROUP: ALOHACARE

Limited Income Newly Eligible Transition Program (LI NET)

LINET is a Medicare program that provides immediate prescription coverage for Medicare beneficiaries who qualify for Medicaid or the Low-Income Subsidy (LIS) and have no prescription drug coverage. Enrollment in LINET is temporary, usually for 1 to 2 months, to provide time to choose a Medicare Part D prescription drug plan. For AlohaCare QUEST members who are Medicare-eligible, but not enrolled in a prescription drug plan (confirm by submitting an E1 transaction to Medicare's online eligibility/enrollment system), bill claim using the following:

BIN: 015599 | PCN: 005440000 |GROUP: may be blank | Cardholder ID: Medicare Claim Number (include letters) [from Medicare red, white, & blue card] | Patient ID (optional): Medicaid ID or Social Security Number

Humana administrated the LI NET program on behalf of CMS. Refer to this webpage for further information:
Medicare’s LI NET Pharmacy Resources - Humana

For AlohaCare QUEST (Medicaid) plan Pharmacy Billing Information, see the QUEST (Medicaid) Prescription Drugs webpage for more details.

Medicare Primary Billing Payer Sheet
For questions about pharmacy processing and claim overrides, contact the OptumRx Pharmacy Help Desk at 844-368-8732 or visit www.optumrx.com (click on Health Care Professionals)

Refill Synchronization

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) and excludes Schedule II and III controlled substances.

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.

If a claim rejects with NCPDP Reject Code 79 (Refill Too Soon), the pharmacy may override the reject with Submission Clarification Code (SCC) 61 (Synchronization Fill - Shortened Days Supply).

General Resources & Contact Information

Pharmacy benefit (pharmacy dispensed drugs) prior authorization requests & status inquiries

OptumRx Pharmacy Services (Prescribers Only)

Phone: 1-800-711-4555
Fax: 1-844-403-1028
Hours: 24 hours, 7 days a week

Claims processing or overrides

OptumRx Medicaid Pharmacy Help Desk (Pharmacies Only)

Phone Number: 1-844-368-8732
Hours: 24 hours, 7 days a week

Medical benefit (physician administered drugs) prior authorization request & status inquiries

AlohaCare Provider Customer Service