Prescription Drugs

Every 3 months, AlohaCare’s Pharmacy and Therapeutics (P&T) Committee reviews drugs on the QUEST (Medicaid) Formulary. This committee includes doctors and pharmacists, who decide which drugs are placed on the formulary.

The list of covered drugs can be found here:

• QUEST (Medicaid) Formulary
• QUEST (Medicaid) WRAP Formulary

The AlohaCare QUEST (Medicaid) Formulary is updated every 3 months and as needed. Please talk with your doctor about any changes to the Formulary that may affect you.

Drugs not listed on the formulary are called non‐formulary drugs. For non‐formulary drugs, you can: 

• Ask your doctor to order a similar drug that is listed in the formulary. 

• Ask your doctor to request an exception so your non‐formulary drug can be covered by AlohaCare. 

• Ask for an exception to cover a non‐formulary drug by calling Customer Service at (808) 973-0712 or toll free at 1-877-973-0712 (TTY/TDD at 1-877-447-5990), 24 hours a day, 7 days a week. 

• You can also submit your pre-approval request by using Prompt PA.  You will need to have the drug name, strength, quantity, and day supply in order to submit your request.  

You should not have to pay for your medicine at the pharmacy. If you pay for your medicine because you do not have your insurance card, you can ask AlohaCare to reimburse you. AlohaCare will review your reimbursement request. We will make a decision within 14 days after they have received your request. You must send in your prescription receipt and itemized printout from the pharmacy. Your request must have the following:

• Your name
• Prescription number
• Date filled
• Pharmacy name and address
• Drug name, strength/form, and quantity received
• Ingredient cost, gross amount due
• Days’ supply
• Price

If you pay for a medicine that needs a pre-approval, you may not get reimbursed for your medicine. You must ask your doctor to submit a prior authorization (pre-approval) request for you.  You can also submit a pre-approval. Please refer to the Getting an Exception to the Formulary section.

You can submit your reimbursement request by filling out the Prescription Reimbursement Claim Form and mailing it to:

AlohaCare Pharmacy Department
1357 Kapiolani Blvd., Ste. G101
Honolulu, HI 96814

We understand that going to the pharmacy every day 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 Optum Home Delivery Pharmacy. To sign up for home delivery, please call OptumRx Home Delivery toll free at 1-844-368-1959. You can also call AlohaCare Customer Service at (808) 973-0712 or toll free at 1-877-973-0712 (TTY/TDD at 1-877-447-5990), 24 hours a day, 7 days a week. 

To order a refill for an existing, unexpired Home Delivery prescription, filled by OptumRx Home Delivery Pharmacy, log into the Pharmacy Member Portal (by OptumRx\. 

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 AlohaCare. 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.

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.
• Requesting for brand drug when generic is available.
• The drug is not on our list.
• Getting an exception to the formulary.
• 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 also need it if you go on vacation and need extra medicine for a long trip. A prior authorization is also needed if your doctor changes you to a higher dose of the drug you are already taking.

Your doctor will send us a prior authorization request if you need to take a drug that requires prior authorization. AlohaCare Pharmacy Department reviews those requests. Your doctor will explain why you need to take that drug. We will tell your doctor within 24 hours if the request has been approved. They will tell you, your doctor, and your pharmacy (if pharmacy information was provide) if the drug was approved. AlohaCare Pharmacy Department will send a letter to you and your doctor if the prior authorization request was denied along with an explanation of the decision. They will explain their decision. They will also tell you ways that the decision can be changed. You can check with your doctor's office if a decision has been made regarding any prior authorization requests. Your doctor will have information about all your prescriptions and final decisions regarding prior authorizations.

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.

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.