Prescription Drugs

Your Pharmacy Drug Benefit

Important Benefit Information for Beneficiaries who Qualify for “Extra Help”:
As a member of AlohaCare Advantage (D-SNP) and AlohaCare Advantage Plus (D-SNP), you are automatically qualified for "Extra Help" to pay for your prescription drug costs. This is also called "Low Income Subsidy" or LIS. You receive help from Medicare to cover your prescription drug program costs, such as premiums, deductibles, some of your Part D copays.

Based on the amount of “Extra Help” received, your low-income subsidy (LIS) copays for a Part D medications are no more than the following indicated in the chart below. See your Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (also known as the Low-Income Subsidy Rider or the LIS Rider), which tells you about your level of drug coverage.

Extra Help LIS Subsidy Level	LIS Level 1	LIS Level 2	LIS Level 3
2026 Generic Drug Copay	$5.10	$1.60	$0.00
2026 Brand Drug Copay	$12.65	$4.90	$0.00
2027 Generic Drug Copay	$5.80	$1.65	$0.00
2027 Brand Drug Copay	$14.40	$5.00	$0.00

Important Message About What You Pay for Vaccines - Our plan covers ACIP recommended Part D vaccines at no cost to you.

Important Message About What You Pay for Insulin - You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on.

OTC Medications and Products Covered by Prescription - Medications and products on this list are covered at a $0 copay with a prescription

Low Income Subsidy (LIS) or “Extra Help”

If you have questions about "Extra Help," call:

The Social Security Administration at 1-800-772-1213 between 8 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call, 1-800-325-0778; or
1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7 days a week.

Medicare Prescription Payment Plan

The Medicare Prescription Payment Plan is a payment option that works with your current AlohaCare Advantage or AlohaCare Advantage Plus drug coverage to help you manage your out-of-pocket costs for drugs covered by your Part D plan by spreading them across the calendar year (January-December). Anyone with a Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage Plan with drug coverage) can use this payment option. All plans offer this payment option, participation is voluntary, and there’s no cost to participate. If you have any questions about this program, Contact the OptumRx Medicare Prescription Payment Plan Member Services to start participating at any time during the calendar year.

OptumRx is AlohaCare’s Pharmacy Benefit Manager (PBM). You can contact the OptumRx Medicare Prescription Payment Plan Member Services at 1-844-368-8729 from 5:00am – 10:00pm CST, 7 days a week. TTY users can call 711. Calls to these numbers are free.

Visit the OptumRx Medicare Prescription Payment Plan website to start participating at any time during the calendar year. Click here to access the form: Medicare Prescription Payment Plan Form

Learn more information about the Medicare Prescription Payment Plan:

Formulary

The formulary is a list of the drugs that we cover. Generally, we will cover the drugs listed on our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and other coverage rules are followed. We may add or remove drugs from our formulary during the year.

You can search our Drug Finder to find the drugs that you can use.

The formulary is a list of covered drugs selected by AlohaCare Advantage (D-SNP) and AlohaCare Advantage Plus (D-SNP), in consultation with a team of health care providers and represents the prescription therapies believed to be a necessary part of a quality treatment program.

Some covered drugs may have additional requirements or limits on coverage. These limitations are marked next to each drug on the formulary with "BvsD," "LA," "PA," "QL" or "ST."

Part B versus D (BvsD): This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
Limited Access (LA): This prescription may be available only at certain pharmacies. For more information, please call AlohaCare Member Services.
Prior Authorization (PA): AlohaCare Advantage (D-SNP) and AlohaCare Advantage Plus (D-SNP), requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you do not get approval, we may not cover the drug.
Quantity Limit (QL): For certain drugs, AlohaCare Advantage (D-SNP) and AlohaCare Advantage Plus (D-SNP), limits the amount of the drug that we will cover.
Step Therapy (ST): In some cases, AlohaCare Advantage (D-SNP) and AlohaCare Advantage Plus (D-SNP), requires you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.

Extended Days Supply - 100 Day Supply Benefit

AlohaCare members can receive up to a 100-day supply of all generic and brand medicines for certain disease states such as:

• Blood Pressure

• Diabetes

• Cholesterol

To search for drugs eligible for a 100-day supply, view the AlohaCare Formulary. Select the "PDF" for your current plan (AlohaCare Advantage (D-SNP) or AlohaCare Advantage Plus (D-SNP)) for a list of all covered drugs.

Drug Recalls and Withdrawals (removed from market)

The U.S. Food and Drug Administration (FDA) is responsible for ensuring drugs are tested to be safe and effective before they become available. Sometimes there can be a drug recall or market withdrawal. A market withdrawal is when a drug company removes a product from the market. This can happen for various reasons. Two examples are product tampering or correcting a minor violation. A drug recall occurs when a drug is removed from the market because it is deemed to be defective or possibly harmful.

There are 2 types of recalls required by the FDA. It is based on the level of danger involved:

Class I: Dangerous or defective products that could cause serious health problems or death. Example: a label mix-up on a lifesaving drug.
Class II: Products that might cause a short-term health problem or pose only a slight threat of a serious nature. Example: a drug that is under-strength but that is not used to treat life-threatening illness.

AlohaCare’s Pharmacy department will tell members, doctors and pharmacies when there is a Class I or II drug recall. We also inform our members in writing when drugs are withdrawn from the market for safety reasons. AlohaCare reviews drug recalls and withdrawals every 3 months. The review takes place in a meeting of the Drug Utilization Review (DUR) Board.

Please talk to your doctor or pharmacist about any details on drug recalls and withdrawals that may affect you.

2024	2025	2026
January 1 - March 31	January 1 - March 31	January 1 - March 31
April 1 - June 30	April 1 - June 30	April 1 - June 30
July 1 - September 30	July 1 - September 30	July 1 - September 30
October 1 - December 31	October 1 - December 31

Coverage Determinations

Medicare Prescription Drug Coverage Determination and Exception Request Form: This form allows you to request a drug that is not covered by our formulary or a drug that needs pre-approval.
Medicare Redetermination Request Form: This form allows you to let us know if you disagree with the determination decision we made.
- AlohaCare Advantage
- AlohaCare Advantage Plus
Prescription Reimbursement Claim Form : This form allows you to file a claim if you paid out of pocket for a prescription. All claims are subject to review and approval. Please remember to always show your member ID card before picking up a prescription.

Transition Policy

If you are a new member of AlohaCare Advantage (D-SNP) or AlohaCare Advantage Plus (D-SNP), you may be taking drugs that are not on our Formulary or that are subject to certain restrictions. Or, you may be a current member and are affected by changes to our Formulary from one year to the next. You should speak with your doctor to decide if you should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug.

2026 Transition Policy
2027 Transition Policy
Temporary 30-day supply of the non-formulary drug if you need a fill for the drug during the first 108 days of your membership.
Temporary 30-day supply of the non-formulary drug if you need a fill for the drug during the first 108 days of the new plan year.
For drugs that are not on our formulary, or that have coverage restrictions or limits (but is otherwise considered a “Part D drug”), we will cover a 30-day supply.
If you are a new member and are a resident 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.

Medication Therapy Management (MTM) Program

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 $1,276 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 808-973-7418 or toll free at 1-866-973-6395, Monday through Friday, 8 a.m. to 5 p.m. HST. TTY/TDD users, please call 1-877-447-5990.

Pharmacy Network

AlohaCare has a network of pharmacies that can fill your medicines.

Pharmacy Finder

To find out if a pharmacy works with AlohaCare, use our online Provider Finder. By clicking on this link, you will be leaving the AlohaCare website. Or you can download the Provider Directory found on the Member Documents page .

Mail Order & Home Delivery

We understand that going to the pharmacy can be hard sometimes. AlohaCare is offering the convenience of home delivery of your medicine. With OptumRx Home Delivery Pharmacy, you can request for drugs you take on a regular basis be delivered to your home. These include drugs that you take every day to treat your condition, such as diabetes, high blood pressure, or asthma.

Ask your doctor if your drug can be filled by OptumRx Pharmacy. To sign up for home delivery, please mail in the OptumRx Pharmacy Home Delivery Service Order Form found on the Member Documents page. If you need help with your Home Delivery drugs, call OptumRx Pharmacy toll free at 800-383-0589. You can also call Customer Service.

General Resources & Contact Information

Contact AlohaCare Member Services

Prescription Drugs

Your Pharmacy Drug Benefit

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