Frequently Asked Questions

Prescriptions must be written by a plan doctor.

Show your ID card when you give your prescription to the pharmacist. There is no co-pay for prescribed Community Care Services (CCS) medications for Medicaid-only members. There may be a co-pay if you have other insurance coverage such as Medicare.

AlohaCare CCS pays for behavioral health medicines; see our Preferred Drug List (PDL) for a complete listing. Doctors and pharmacists make the list. Your doctor or provider will use the list when prescribing drugs for you. Some drugs will require approval through a Drug Coverage Request Form that is filled out by your doctor. This applies to drugs that require prior authorization (or pre-approval) and those drugs not listed on the PDL. The list will also have drugs that may have limits such as prior authorization, quantity limits, step therapy, age limits, or gender limits 

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

Please go to Pharmacy Services to get more information about what is covered, getting an exception to the formulary and how to submit prior authorizations for drugs that are not listed on the PDL.  

If you have questions about prior authorization requests, please call AlohaCare Pharmacy Department at 808-973-7418 or toll-free at 1-866-973-7418, Monday-Friday 8:00 AM to 5:00 PM.  

Medicare Part D is a prescription drug benefit. It is available to everyone with Medicare. This means that most prescription drugs will be covered under your Medicare Part D plan, not AlohaCare CCS. AlohaCare CCS may cover certain CCS drugs that are not covered under Medicare Part D, such as over-the counter drugs or certain multivitamins such as diphenhydramine, Vitamin B Complex, and Thiamine.  

The plan does not pay for these medicines: 

• That are not used for behavioral health conditions. 

• Drugs covered by your Medicare Part D plan. 

• Those used to help you get pregnant. 

• Those used for anorexia or weight gain. 

• Those used for erectile dysfunction. 

• Those that are used for cosmetic purposes or to help you grow hair. 

• DESI (Drug Efficacy Study Implementation) drugs and drugs that are identical, related or similar to such drugs. 

• Investigational or experimental drugs. 

• Those used for any purpose that is not medically accepted by the Food & Drug Administration (FDA) 

• Drugs related to food supplements 

• Bulk powder drugs 

You will get all medicines that are medically necessary for your care if it is a drug that is covered for behavioral health conditions and you have Medicaid. If you have Medicare Part D, these should be billed to your Medicare Plan. All drugs your providers order for you may be covered by AlohaCare Community Care Services (CCS) if they are on the Preferred Drug List. You may also request copies of the PDL by calling AlohaCare CCS Member Services at 808-450-3386 or 1-888-397-9899 toll free. TTY/TDD users call 1-877-447-5990. In some cases, we require you to try another drug before approving the one you originally asked for. We may not approve your requested drug if you do not try the alternative drug first. 

For more information about the Preferred Drug List, please go to “What is Covered” on the Pharmacy Services page

Yes. Generic drugs work the same as brand drugs. They have the same ingredients as brand drugs.

Sometimes you may pay for medications out of pocket at a retail drug store. You may then submit a claim form and your receipts to recover your costs. This is called Direct Member Reimbursement (DMR).

If we find that medication is a covered benefit, you will receive a check for the plan-contracted price. This may be different from the retail price and may not equal the amount paid.

It usually takes 4 to 6 weeks from the date you mail in the Direct Member Reimbursement (DMR) form. Please allow up to 14-day calendar days for us to make a decision on your DMR requests. Be sure that your form is completed and has all the information. Otherwise, your request may be delayed or denied. Formulary guidelines will apply to all reimbursement requests.

You may not like the decision we make. You have the right to appeal it.

You may submit an appeal by calling AlohaCare CCS Member Services at 808-450-3386 or 1-888-397-9899 toll free. TTY/TDD users call 1-877-447-5990.