Q. How does AlohaCare decide which drugs to put on the formulary list?
A. The drugs on this list are chosen by the Pharmacy and Therapeutics (P&T) Committee. This committee is a team made up of doctors and pharmacists from IngenioRx. They also get input from the medical community. The P&T committee meets every 3 months to decide which drugs should be on the list. The drugs chosen are the ones that will serve you best. The P&T committee also reviews Food and Drug Administration (FDA) reports. These reports talk about new drugs approved for use and how well current drugs work. These reports help the committee know if they should add or remove drugs from the list.
Q. What is Prior Authorization?
A. Certain drugs require a prior authorization. That means that AlohaCare may have to approve a drug your doctor wants you to take before AlohaCare will pay for the drug. We only do this with some drugs. We may ask for it if:
- Our formulary drug list says the drug is “PA” or prior authorization is needed.
- The drug is not on our list.
- The drug is being used for a health condition that the Food and Drug Administration (FDA) did not approve.
- The prescription is being refilled too soon after it was first filled. For example, if your drug is lost, stolen or spilled, you might need a prior authorization to get an early refill. Or, you might need it if you go on a vacation and need extra medicine for a long trip. You might also need a prior authorization if your doctor changes you to a higher dose of the drug you are already taking.
Your doctor will send us a request if you need to take a drug that needs prior authorization. AlohaCare uses IngenioRx to review those requests. Your doctor will explain why you need to take that drug. IngenioRx will review the request. They will tell your doctor within 24 hours if it is OK to prescribe it for you. They will tell you, your doctor, and your pharmacy if it is OK or not for you to get that drug. If it is denied, IngenioRx will send a letter to you and your doctor. They will explain their decision. They will also tell you how you can ask us to change our decision. If you are waiting to hear if your drug was allowed, you can check with your doctor’s office. We give your doctor all the information about your prescription.
Q. Why do we have a Prior Authorization process?
A. We ask for prior authorization to make sure:
- A drug is safe for you to take.
- You take the right amount of the drug.
- The drug is a good drug to treat your condition.
- It was prescribed to you by the right person.
- The drug will not mix in a dangerous way with any other drugs you take.
- An expensive drug prescribed by your doctor is necessary when there is a less expensive drug that will work for your condition.
Q. What is a utilization control?
A. We want to keep you safe when you take your medicine. Utilization controls are rules in the pharmacy computers for certain drugs. These are alerts for your pharmacist to make sure that the drug is safe for you. These rules will limit whether or not you can take a certain drug and how much you can take. These rules will make sure the drug will help you and not hurt you.
Types of utilization controls
Dose/Age Check: This check is to make sure that you take the right amount of a drug for your age, weight, and height. The FDA has directions for how much of a drug a person of a certain age, weight, and height can take. We have dose/age checks to make sure the drug you are prescribed follows these directions.
Drug Interaction Screens: Some people see more than one doctor. Each doctor may prescribe a different type of drug for you. Sometimes the different drugs taken together can be dangerous to your health. That is why the pharmacy computers do drug interaction screens. These screens check to make sure the drug you are prescribed will not interact with another drug you take. If the pharmacy notices a problem, they will tell you and your doctor.
We want to keep you safe. That is why we follow these processes. We do not want you take a drug if there is a danger. We also conduct drug utilization reviews. Our pharmacy computers review your drug records each time you fill a prescription. We make sure there is no problem with the drugs you take.