You pay nothing for prescribed drugs that are on AlohaCare's Community Care Services (CCS) list of covered drugs. These drugs are covered in full by your AlohaCare CCS plan. 

The Preferred Drug List (PDL) is the list of drugs covered by AlohaCare. AlohaCare asks doctors to prescribe medications from the AlohaCare Community Care Services (CCS) Formulary. Some drugs will need your doctor to ask for prior approval before the medication can be given to you at the pharmacy. 

The list of covered drugs can be found here: 

• AlohaCare CCS (Behavioral Health) Drug Look-Up Tool 

• AlohaCare CCS (Behavioral Health) Preferred Drug List (PDF) 

• AlohaCare CCS (Behavioral Health) Machine Readable File (JSON) 

You may also request copies of the PDL by calling Member Services at 808-450-3386 or toll-free 1-888-397-9899. TTY/TDD users can call 1-877-447-5990.

Prescription medicines are covered at no cost to you when: 

• Your doctor gives you a prescription for a drug and the drug is listed on the AlohaCare CCS Formulary. 

• We approve your non-formulary drug as an exception request. 

• You are started on a drug while you are in an emergency room or hospital. 

• You receive the drug while in a rest home, nursing home, or convalescent hospital and it is ordered by a doctor for a covered service. 

• You get them through a pharmacy in the AlohaCare Pharmacy Network. 

If you have questions or problems with your prescription, call AlohaCare Member Services at 1-808-450-3386 or toll-free at 1-888-397-9899, 24 hours a day, 7 days a week.

Some drugs are not covered under the AlohaCare CCS program, such as:  

• Drugs that are not used for mental health conditions 

• Drugs covered by your Medicare Part D plan 

• Drugs that are not used for indications that is not medically accepted 

• Investigation or experimental drugs  

AlohaCare will only pay for over-the- counter (OTC) items listed on the PDL. Examples of OTC items listed on the PDL include: 

• Diphenhydramine 

• Vitamin B complex 

• Thiamine

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

The list of covered drugs can be found under the section, “What is covered?”.

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 or OptumRx will tell members, doctors and pharmacies when there is a Class I or II drug recall. AlohaCare or OptumRx will also inform our members in writing when drugs are withdrawn from the market for safety reasons. AlohaCare reviews drug recalls and withdrawals during a Drug Utilization Review (DUR) meeting every 3 months. 

Please talk to your doctor or pharmacist about any details on drug recalls and withdrawals 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 AlohaCare Pharmacy Department at 808-973-7418 or submitting pre-approval request through Prompt PA: https://alohacare.promptpa.com/. You will need to have the drug name, strength, quantity, and day supply in order to submit your request.  

If your doctor orders a brand name drug, and there is a generic available, AlohaCare will cover the generic medication. If your doctor says that you must have the brand name drug instead of the generic, they must submit a prior authorization request to AlohaCare Pharmacy Department. 

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 has a network of pharmacies that can fill your medicines. 

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. 

AlohaCare only works with pharmacies in Hawai’i. Pharmacies outside of Hawaiˊi are not in AlohaCare’s pharmacy network. If you need to use a pharmacy on the mainland (out of area), you will need to ask AlohaCare to add an override to let you use that pharmacy. Prescriptions may be covered on the mainland (out of area) for emergency or urgent services only. AlohaCare will review your request on a case-by-case basis for medical necessity.

You can call AlohaCare CCS Member Services at 808-450-3386 or toll-free 1-888-397-9899. TTY/TDD users can call 1-877-447-5990.

Specialty drugs are usually high-cost medicines used to treat complex or rare conditions. OptumRx Specialty Pharmacy will provide your specialty drugs. Your doctor or pharmacy will know if a drug needs to be filled at a Specialty Pharmacy. 

OptumRx Specialty Pharmacy is our preferred pharmacy, and they have nurses and pharmacists who can talk with you about your condition and how to use your medicine. OptumRx will deliver specialty drugs to your home. 

If you need help with your specialty drugs, call OptumRx Specialty Pharmacy toll free at 1-855-427-4682. 
 
You can also call AlohaCare CCS Member Services at 808-450-3386 or toll-free 1-888-397-9899. TTY/TDD users can call 1-877-447-5990.

AlohaCare offers a mail-order pharmacy service. It allows members to receive up to a 100-day supply of certain generic maintenance medications delivered to their door, saving them time and money. This service increases medication adherence while offering significant cost savings.  

Ask your doctor if your drug can be filled by Optum Home Delivery Pharmacy. To sign up for home delivery, please mail in the OptumRx New Home Delivery Prescription Order Form. If you need help with your Home Delivery drugs, call Optum Rx Home Delivery toll free at 1-877-795-4521. You can also call AlohaCare CCS Member Services at 808-450-3386 or toll-free 1-888-397-9899. TTY/TDD users can call 1-877-447-5990.

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) . 

You can call AlohaCare CCS Member Services at 808-450-3386 or toll-free 1-888-397-9899. TTY/TDD users can call 1-877-447-5990.

We can help with: 

• Questions about a drug. 

• Any problems with getting prescription(s) filled at the pharmacy. (Your prescriptions should be of no cost to you so please do not pay for any prescriptions). 

• You are not in Hawaiˊi and need to fill a prescription. Prescriptions are covered through AlohaCare's network pharmacies within Hawaiˊi. Prescriptions may be covered outside of Hawaiˊi for emergency or urgent services only. 

• You need an interpreter to talk with the pharmacy about getting your medication. 

• You have an emergency and need drugs. AlohaCare will provide you with up to a 7-day supply of the drug. 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).