Frequently Asked Questions
Q: How do I get a prescription?
A: Prescriptions must be written by a plan doctor.
Q: What is the process for getting a prescription filled?
A: Show your ID card when you give your prescription to the pharmacist. There is no co-pay for prescribed medications for Medicaid-only members. There may be a co-pay if you have other insurance coverage such as Medicare.
Q: What medicines does 'Ohana CCS pay for?
A: 'Ohana 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 Coverage Determination Request (CDR) filled out by your doctor. (This applies to drugs that require prior authorization 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.
Q: Does 'Ohana CCS pay for medications if I have Medicare?
A: 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 'Ohana CCS Medicaid. 'Ohana CCS may cover the drugs not covered under Medicare Part D.
Q: Are there medicines 'Ohana CCS will not pay for?
A: The plan does not pay for these medicines:
- 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.
Q: Can I get any medicine I want?
A: You will get all medicines that are medically necessary for your care. All drugs your doctors order for you may be covered if they are on the Preferred Drug List. Call Customer Service with any questions. 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.
Q: Are generic drugs as good as brand-name drugs?
A: Yes. Generic drugs work the same as brand drugs. They have the same ingredients as brand drugs.
Q: What is a medication Direct Member Reimbursement?
A: 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).
Q: Where do I send my DMR request?
Q: What do I need to include with each DMR request for approval?
- A completed, signed Direct Member Reimbursement form.
- A detailed prescription receipt (handwritten receipts will not be accepted) or pharmacy printout with the following information: member name, pharmacy name, physician name, drug name, drug strength, quantity dispensed, a day's supply and the amount you paid.
- A cash register receipt that shows the date the prescription was paid for and what amount was paid.
- All the above information must be included. Otherwise, the DMR will be denied.
- You will then be able to send in your request again with the missing information.
Q: How much will I get back?
A: 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.
Q: How long should I expect to wait for my reimbursement?
A: It usually takes 4 to 6 weeks from the date you mail in the DMR form. 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.
Q: What if I don't like the decision that was made?
A: You may not like the decision we make. You have the right to appeal it.