Prescription Drugs
AlohaCare covers certain prescription drugs for our QUEST Integration members.
Important Notice:
Beginning 2/1/2021, Basaglar (insulin glargine) will no longer be on the AlohaCare QUEST Integration formulary. Semglee (insulin glargine) is now on the AlohaCare QI formulary as the preferred basal insulin with the following quantity limits:
| Semglee vial | 5 vials per month |
| Semglee pen | 3 boxes per month |
If you are taking Basaglar or Lantus, please ask your doctor to send a new prescription for Semglee to your pharmacy. Semglee is the same drug as Basaglar and Lantus.
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 and the prescription is filled at a network pharmacy. See below for information on restrictions and limitations. We may add or remove drugs from our formulary during the year. We will provide updates when the formulary changes.
For more information, click
here. The formulary will tell you about:
- The drugs included in our formulary
- Quantity limits for drugs
- Restrictions that apply to drugs such as prior authorization requirements
- How to obtain prior authorization for a drug, if required
- How your physician may request an exception to our formulary, including the documentation that we require to review this request
- How you or your physician may appeal our decision not to approve the request for an exception
- The Process of generic substitution of drugs
- Step therapy requirements
- Therapeutic interchange requirements
- Any other requirements, restrictions, limitations, or incentives that apply to the use of certain drugs
Every 3 months, AlohaCare's Pharmacy and Therapeutics (P&T) Committee may change medications to the QUEST Integration Formulary. This committee includes doctors and pharmacists, and they decide which medications are on the list.
Below are the changes from each meeting. Please talk with your doctor about any medication changes that may affect you.
Keeping you informed
The Food and Drug Administration (FDA) ensures that a drug is safe and effective before it is available on the market. The FDA can recall a drug so it is not available.
A recall can happen when a drug is found to be either defective or could be harmful for use.
There are 3 types of recalls required by the FDA. The type of recall 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 mixed 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 is not used to treat life-threatening illness.
- Class III: Products that may not cause any bad health reactions, but violate FDA labeling or manufacturing laws. Example: A minor pill bottle defect.
Drug companies may also decide to remove a drug or product for other reasons. This is called withdrawal. Example: A drug is removed from the market due to tampering.
The AlohaCare Pharmacy Department will tell members, doctors, and pharmacies when there is a Class I or Class 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 with a group of pharmacists, doctors, and nurse practitioners. This meeting is called the Pharmacy and Therapeutics (P&T) Committee.
Please talk to your doctor about any details on drug recalls and withdrawals that may affect you.
2020 Summaries:
There is little difference between a brand name drug and the generic version. Generic drugs have the same ingredients as brand name drugs. They are usually a different color and shape. Generic drugs are not as expensive as brand name drugs. Your pharmacy will fill your prescription with a generic drug if it is available. Generic medications are as safe and effective as their brand name drugs.
AlohaCare has a committee of physicians and pharmacists that decide about our medication procedures. They review the available drugs and select the ones that they believe are the best for our members.
Most of the time, you will get a 30 day supply unless your doctor orders a supply for a shorter period of time, based on your need for the drug (for example, antibiotics). Some covered drugs may have additional requirements or limits on coverage. These limitations are marked next to each drug on the formulary with "LA," "PA," "QL" or "ST." Situations in which a drug limit may apply include:
- Limited Access (LA): This prescription may be available only at certain pharmacies. For more information, please call AlohaCare Member Services.
- Prior Authorization (PA): AlohaCare QI 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 QI limits the amount of the drug that we will cover.
- Step Therapy (ST): In some cases, AlohaCare QI 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.
Generic substitution or therapeutic interchange may also apply. You may be asked to take a drug that is chemically identical (not brand name) or chemically different from the drug originally prescribed. This substitution or change will have the same therapeutic purpose and will be used for the same FDA approved conditions. The pharmacist or prescriber may ask you to take this drug and will explain the reasons why he or she believes this is a better drug choice for you. You do not have to agree. If you do not agree, you or your physician may request a prior authorization (PA).
You pay nothing for prescribed drugs that are on AlohaCare's list of covered drugs. These drugs are covered in full by your AlohaCare QUEST Integration plan.
If your drug is not listed, you or your doctor can ask for a prior authorizations (PA) by calling Customer Service at 973-0712 or toll-free at 1-877-973-0712 (TTY/TDD: 1-877-447-5990). If you have an email address, you can also fill out the
Drug Request Form and submit directly to us. We will ask your doctor for the reason why you are requesting a certain drug. We will let you and your doctor know if we approve your request.