Formulary
AlohaCare QUEST (Medicaid) Formulary
AlohaCare covers all medically necessary Med-QUEST-covered 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.
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.
Some drugs require a prior authorization (PA) to explain to us why a specific medication or a certain amount of a medication is needed. We must approve the request before the member can get the medication. Reasons why we may prior authorize a drug includes, but is not limited to:
- There is a generic or pharmacy alternative drug available;
- The drug can be misused/abused; or
- There are other drugs that must be tried first.
Some drugs may also have a quantity (amount) limit or an age limit.
Drugs for erectile dysfunction, infertility, and cosmetic purposes are not covered.
For a complete list of non-covered and excluded drugs, please see our Formulary document, under "Drugs That Are Not Covered by AlohaCare QUEST (Medicaid)."
Electronic prior authorization (ePA) is preferred method for PA submission for AlohaCare QUEST (Medicaid).
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.
AlohaCare requires the use of generic drugs if they are available. If you believe that it is medically necessary for your patient to have a brand name drug, you may submit a prior authorization request for review. OptumRx will determine whether to approve the brand name medication.
Our formulary and list of medications that require prior authorization can change, so it is important for you or your patient to check this information when your patient needs to fill or refill a medication.
For our member’s convenience and to encourage medication adherence, we cover up to a 100-day supply of generic maintenance medications. You can search our
Drug Finder to find drugs eligible for this extended supply.
For members with Community Care Services (CCS) benefits, certain drugs must be billed to CCS. These drugs include, but is not limited to:
- Drugs used for behavior health
- Drugs used for drug or alcohol addiction
Please refer to the CCS website for more information.
See below for a summary of drug recalls and withdrawals:
Please refer to the Provider Advisories page for Drug Safety Communication Alerts.
Pharmacy Billing Information
Pharmacy Billing Information for QUEST (Medicaid):
BIN: 610011 | PCN: IRX |GROUP: ALOHACAID
QUEST (Medicaid) is the payer of last resort. For coordination of benefits (COB) billing for members with multiple prescription drug plans, bill other plan as primary plan and QUEST (Medicaid) plan (AlohaCare member ID starts with zeroes) as secondary plan.
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
QUEST Medicaid 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).
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).
TRUE METRIX is the preferred brand for diabetes testing products for AlohaCare.
Prescribers: Send a prescription to your patient’s pharmacy for a TRUE METRIX or TRUE METRIX AIR glucometer, test strips, and lancets.
Pharmacies: For a no-charge TRUE METRIX glucometer, transmit claims to Change Healthcare using the following billing information:
BIN: 018844 | PCN: 3F | ID: TRPT5023493 | Group: FVTRUEPORT50
For pharmacy processing questions, please call the True Metrix Free Meter Fulfillment Center at 1-866-788-9618, Monday through Friday between 9AM-5PM EST. Once a free meter is processed for reimbursement, the claim cannot be submitted to any other third-party payer. Limit one meter per patient every 12 months.
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 Clinical Programs and Services
Home Delivery is a service that AlohaCare offers to our QUEST (Medicaid) members. With Home Delivery, members have the convenience of getting maintenance medications delivered directly to their home. The Home Delivery Program is administered through OptumRx Home Delivery Pharmacy.
To send electronic prescriptions for home delivery/mail order select OptumRx Home Pharmacy in your ePrescribing platform. Please note that the pharmacy address will display as Overland Park, KS.
OptumRx Mail Order Pharmacy Phone: 800-791-7658 | Fax: 800-491-799
AlohaCare’s specialty pharmacy services will be administered by OptumRx Specialty Pharmacy.
To send electronic prescriptions for specialty drugs, select OptumRx Specialty Pharmacy in your ePrescribing platform. Please note that the pharmacy address will display as Jeffersonville, IN.
OptumRx Specialty Pharmacy Phone: 855-427-4682
The AlohaCare Lock-In Program enrolls select members who are using more than an average daily 90 MME (morphine milligram equivalents) of opioids and receiving opioids from multiple prescribers and/or pharmacies. Members are required to obtain prescription opioids from one doctor or clinic and one pharmacy. Opioids will not be covered by AlohaCare if they are prescribed by other doctors or filled by other pharmacies, even if they are in our network. To request a different doctor, clinic, or pharmacy, please submit a Pharmacy Lock-In & Designated Prescriber Selection Form found on the
Member Documents page.
This change only affects access to prescription opioids. Access to other types of medications will not change. Visit
www.hhs.gov/opioids for State and Federal public health resources for more information.
General Resources & Contact Information
| Pharmacy benefit (pharmacy dispensed drugs) prior authorization requests & status inquiries | OptumRx Pharmacy Services (Prescribers Only) - Phone: 800-711-4555
- Fax: 844-403-1029
- Hours: 24 hours, 7 days a week
|
| QUEST (Medicaid) claims processing or overrides | OptumRx Medicaid Pharmacy Help Desk (Pharmacies Only) - Phone Number: 844-368-8732
- Hours: 24 hours, 7 days a week
|
| Medical benefit (physician administered drugs) prior authorization request & status inquiries | AlohaCare Provider Customer Service |
