AlohaCare is pleased to announce that effective January 1, 2022, IngenioRx is our new Medicare PBM partner.
Please remind members to show their new member ID cards to their pharmacy. To avoid potential disruption in services at the pharmacy, please provide a copy of the attached new billing information to your AlohaCare Medicare patients. We have notified the pharmacies of these changes.
New AlohaCare Advantage Plus (Medicare) Pharmacy Billing Information:
RXBIN: 020388 | RXPCN: IRXMEDD | RXGRP: RX42AD
Member ID Format: 15 digits, alphanumeric
Person Code: 2 digits, append to Member ID
For members without a new AlohaCare Medicare ID card, please advise the pharmacy to submit an E1 transaction to receive updated eligibility information. If after submitting an E11 transaction additional assistance is still needed, the pharmacy may contact IngenioRx Pharmacy Help Desk at 1-833-409-1225.
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.
You can search our Drug Finder
to find drugs that are on our Formulary.
Requests will be presented at IngenioRx's next Pharmacy & Therapeutics (P&T) Committee meeting for review and consideration.
Part D-Excluded Drugs
For members with QUEST Integration (Hawai`i Medicaid) benefits, certain drugs not covered by Medicare (e.g. over-the-counter products) may be covered when benefits are coordinated through the QUEST Integration plan.
Medical Injectables & Infused Drugs
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:
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
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.
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 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
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 IngenioRx have partnered with CVS Caremark and OutcomesMTM to perform 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)
- Rheumatoid Arthritis (RA), 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 $4,696 in 2022.
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 our partners IngenioRx, CVS Caremark or OutcomesMTM. 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 15-30 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.
With mail order, members have the convenience of getting up to a 100-day supply of maintenance medications delivered directly to their home.
IngenioRx offers an option that is administered by IngenioRx Home Delivery Pharmacy with Hawai`i-based dispensing overseen by IngenioRx's operational partner, CVS.
To send electronic prescriptions for home delivery/mail order select IngenioRx Home Delivery Pharmacy in your ePrescribing platform. Please note that the pharmacy address will display as Mount Prospect, Illinois, however, the dispensing pharmacy is location on O`ahu.
IngenioRx Home Delivery Pharmacy. Phone: 833-203-1742 | Fax: 800-378-0323
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
BIN: 020388 | PCN: IRXMEDD |GROUP: RX42AD
For coordination of benefits (COB) billing of Medicare Part B claims
(e.g. diabetic testing supplies and nebulizer drugs) and QUEST Integration claims
, bill Medicare plan (AlohaCare member ID starts with MEM) as primary plan and QUEST Integration plan (AlohaCare member ID starts with zeroes) as secondary plan. See the Pharmacy Billing Information section of the QUEST Integration Prescription Drugs webpage
for more details.
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
For questions about pharmacy processing and claim overrides, contact the IngenioRx Pharmacy Help Desk or visit https://www.caremark.com/pharmacists-medical-professionals.html
.Medicare Primary Billing Payer Sheet
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.
- A daily cost-sharing rate will be applied for a prorated copayment based on the days’ supply dispensed for each medication.
- If a claims reject with NCPDP Reject Code 79 (Refill Too Soon), the pharmacy may override the reject with either Submission Clarification Code (SCC) 61 (Synchronization Fill - Shortened Days Supply).
General Resources & Contact Information
|Pharmacy benefit (pharmacy dispensed drugs) prior authorization requests & status inquiries|
IngenioRx Pharmacy Services (Prescribers Only)
- Phone: 1-833-293-0661
- Fax: 1-844-521-6938
- Hours: 24 hours, 7 days a week
|Claims processing or overrides|
IngenioRx Medicaid Pharmacy Help Desk (Pharmacies Only)
- Phone Number: 1-833-409-1225
- Hours: 24 hours, 7 days a week
|Medical benefit (physician administered drugs) prior authorization request & status inquiries |
AlohaCare Provider Customer Service