Plan Summaries

Hawaii Fee-For-Service Plans

2/1/2009

Plan ID: 100
Plan Name: Fee-For-Service (FFS) – For members not in a managed care plan. This plan provides full drug coverage.

Plan ID: 200
Plan Name: Fee-For-Service Long Term Care (LTC) - This plan covers FFS Long Term Care members, and provides full LTC drug coverage.

Plan ID: 220
Plan Name: QExA LTC/w/o Medicare - This plan covers QExA enrolled Long Term Care members, providing full LTC drug coverage for drugs prescribed by a dentist.

Plan ID: 300
Plan Name: Community Care Services (CCS) - This is the State of Hawaii’s Mental Health Program. ACS is responsible for processing non-BHO (behavioral health only) drugs. Hawaii Med-QUEST FFS Program does not cover behavioral health drugs for this plan.

Plan ID: 310
Plan Name: LTC Community Care Services - This plan is a duplicate of Plan 200, but covers only non-BHO FFS medications. If a member has active coverage in both plans 200 and 300, a derived plan 310 is assigned and the Eligibility plan hierarchy is bypassed.

Plan ID: 500
Plan Name: Hospice - This program covers Medicaid members who are currently in a Hospice environment. All claims submitted POS for Hospice members will deny for Drug Not Covered unless a Prior Authorization is on file (see section 4.2.5.) In certain cases, Hawaii Hospice may determine that Hawaii Med-QUEST FFS should pay for certain drug claims that are not covered by Hospice, but all drug claims require a Prior Authorization.

Plan ID: 515
Plan Name: QExA Hospice/w/o Medicare - This plan covers QExA enrolled Hospice Care members, providing drug coverage by PA for non-hospice related drugs prescribed by a dentist.

Plan ID: 600
Plan Name: State of Hawaii Organ, Tissue, and Transplant (SHOTT) - Members in this plan are awaiting transplants. This plan provides full FFS drug coverage (based on plan 100) for providers in the State of Hawaii only.

Plan ID: 800
Plan Name: Office of Youth Services (OYS) – Members in this plan include children who have been incarcerated and may have coverage under another Med-QUEST FFS plan. This plan’s drug coverage is the same as that of Plan 100 – FFS. This is the only plan assigned to Group 2000.

Plan ID: 900
Plan Name: Dental QUEST/QExA – Members in this plan are ONLY able to obtain prescriptions prescribed by a dentist (provider specialty codes = 71, 72, or 73). Drug coverage for this plan mimics FFS plan 100.

Plan ID: 901
Plan Name: Dental QUEST Children with Behavioral Health/QExA – This plan is a duplicate of plan 900 (Dental QUEST), minus Behavioral Health drug coverage. Members in this plan are only able to obtain prescriptions written by a dentist (provider specialty codes = 71, 72, or 73).

Plan ID: 905
Plan Name: QUEST Net Medical FFS Window - This group of members are only able to obtain medications on the QUEST Net formulary. Those medications are as follows: cephalexin, erythromycin (all salts), amoxicillin, penicillin VK, ampicillin, doxycycline, tetracycline, bacitracin ophthalmic, chloramphenicol ophthalmic, erythromycin ophthalmic, Neosporin ophthalmic ointment, SMZ-TMP, sulfacetamide ophthalmic, otic polymixin/neomycin/hydrocortisone, family planning supplies and devices, generic birth control, and medroxyprogesterone.

Plan ID: 910
Plan Name: QUEST Net Dental Restricted - Members in this plan will only be able to obtain prescriptions on the QUEST Net formulary prescribed by a dentist (provider specialty codes = 71, 72, or 73).

Plan ID: 999
Plan Name: Prisoners, QMB, QDWI, SLMB, and PACE - Members in this plan include adults who have been incarcerated or have active coverage under another Med-QUEST FFS plan. This plan has no drug coverage.

Medicare Part D (Medicare D) Plans

Plan ID: 110
Plan Name: FFS/Medicare D - This plan provides FFS drug coverage (based on plan 100) for drugs excluded by Medicare D.

Plan ID: 210
Plan Name: FFS LTC/Medicare D - This plan covers FFS Long Term Care members, and provides full LTC drug coverage (based on plan 200) for drugs excluded by Medicare D.

Plan ID: 215
Plan Name: QExA LTC/Medicare D - This plan covers QExA enrolled Long Term Care members, providing LTC drug coverage for drugs excluded by Medicare D and prescribed by a dentist. The QExA plan is responsible for excluded Part D drugs not prescribed by a dentist.

Plan ID: 301
Plan Name: CCS/Medicare D - This plan covers all non-BHO FFS medications (based on plan 300) for drugs excluded by Medicare D.

Plan ID: 311
Plan Name: LTC CCS/Medicare D - This plan covers all non-BHO LTC FFS medications (based on plan 310) that are excluded by Medicare D. If a recipient is eligible for both plans 210 and 301, a derived plan 311 is assigned and the Eligibility plan hierarchy is bypassed.

Plan ID: 510
Plan Name: Hospice/Medicare D - This plan has no drug coverage (based on plan 500), except with PA approval for non-hospice drugs on the Medicare Part D excluded drug list.

Plan ID: 520
Plan Name: QExA Hospice/Medicare D - This plan covers QExA enrolled Hospice Care members, providing drug coverage by PA for non-hospice related drugs excluded by Medicare D and prescribed by a dentist. The QExA plan is responsible for excluded Part D drugs not prescribed by a dentist.

Plan ID: 610
Plan Name: SHOTT/Medicare D - Members in this plan await transplants. This plan provides FFS coverage for medications excluded by Medicare D for providers in the State of Hawaii only.

Plan ID: 902
Plan Name: Dental QUEST Children with Behavioral Health/Medicare D - This plan is a duplicate of plan 901, for medications excluded by Medicare D. Members in this plan are ONLY able to obtain coverage for prescriptions prescribed by a dentist (provider specialty codes = 71, 72, or 73).

Plan ID: 903
Plan Name: Dental QUEST-QExA/Medicare D – Drug coverage for this plan is based on FFS plan 900, but only covers medications excluded by Medicare D. Members in this plan are ONLY able to obtain coverage for prescriptions prescribed by a dentist (provider specialty codes = 71, 72, or 73).

Plan ID: 907
Plan Name: QUEST Net Medical/Medicare D – This plan has no drug coverage, as Medicare D does not exclude coverage for medication on the QUEST Net formulary (based on Plan 905).

The formulary medications are as follows: cephalexin, erythromycin (all salts), amoxicillin, penicillin VK, ampicillin, doxycycline, tetracycline, bacitracin ophthalmic, chloramphenicol ophthalmic, erythromycin ophthalmic, Neosporin ophthalmic ointment, SMZ-TMP, sulfacetamide ophthalmic, otic polymixin/neomycin/ hydrocortisone, family planning supplies and devices, generic birth control, and medroxyprogesterone.

Plan ID: 911
Plan Name: QUEST Net Dental Restricted/Medicare D - This plan has no drug coverage, as Medicare D does not exclude coverage for medications on the formulary (based on plan 910). If this plan covered Medicare D excluded drugs, then members would ONLY be able to obtain coverage for prescriptions prescribed by a dentist (provider specialty codes = 71, 72, or 73).

State Prescription Assistance Program (SPAP) Plans

(coverage only for SPAP eligible Medicare Part D plans)

SPAP discontinued July 1, 2011

Plan ID: 012
Plan Name: SPAP Default – This plan provides $2.40/$6.00 co-pay reimbursement for drugs covered by Medicare D for dual eligibles (Medicaid and Medicare) that are newly eligible for Medicare D, and CMS has not completed PDP auto-enrollment, or low income subsidy (LIS) information has not been transmitted to the PDP.

Plan ID: 112
Plan Name: FFS-QExA/SPAP - This plan provides $1.10/$3.20 co-pay reimbursement for drugs covered by Medicare D. Related Plans:

Medicaid: 100 – Fee-For-Service
Dual: 110 – FFS/Medicare D

Plan ID: 312
Plan Name: CCS/SPAP - This plan provides $1.10/$3.20 co-pay reimbursement for drugs covered by Medicare D. Related Plans:

Medicaid: 300 – Community Care Services
Dual: 301 – CCS/Medicare D

Plan ID: 612
Plan Name: SHOTT/SPAP - This plan provides $1.10/$3.20 co-pay reimbursement for drugs covered by Medicare D. Related Plans:

Medicaid: 600 - SHOTT
Dual: 610 – SHOTT/Medicare D

Plan ID: 712
Plan Name: Medicare D Only/SPAP - This plan provides $2.40/$6.00 co-pay reimbursement for drugs covered by Medicare D. Members enrolled in this plan do not have Med-QUEST FFS coverage.

Plan ID: 912
Plan Name: QUEST Children with Behavioral Health-QExA/SPAP - This plan provides $1.10/$3.20 co-pay reimbursement for drugs covered by Medicare D. Related Plans:

Medicaid: 901 - Dental QUEST Children with Behavioral Health
Dual: 902 – Dental QUEST Children with Behavioral Health/Medicare D

Plan ID: 913
Plan Name: QUEST/SPAP - This plan provides $1.10/$3.20 co-pay reimbursement for drugs covered by Medicare D. Related Plans:

Medicaid: 900 – Dental QUEST
Dual: 903 – Dental QUEST/Medicare D

Plan ID: 914
Plan Name: QUEST Net Medical – FFS Window/SPAP - This plan provides $1.10/$3.20 co-pay reimbursement for drugs covered by Medicare D. Related Plans:

Medicaid: 905 - QUEST Net Medical – FFS Window
Dual: 907 – QUEST Net Medical/Medicare D

Plan ID: 915
Plan Name: QUEST Net Capitated Plan/SPAP - This plan provides $1.10/$3.20 co-pay reimbursement for drugs covered by Medicare D. Related Plans:

Medicaid: 910 – QUEST Net Dental Restricted
Dual: 911 – QUEST Net Dental Restricted/Medicare D

Plan ID: 992
Plan Name: PACE/SPAP - This plan provides $1.10/$3.20 co-pay reimbursement for drugs covered by Medicare D. Related Plan:

Medicaid: 999 - Prisoners, QMB, QDWI, SLMB and PACE

Plan ID: 700
Plan Name: SPAP for 100-135% of FPL. This plan effective July 1, 2006. Plan provides co-pay reimbursement for drugs covered by Medicare D. It applies when the participant’s income is 101% through 135% of the Federal Poverty Level. As with plans 012, 701, and 712, this plan allows for a $2.40/$6.00 co-pay reimbursement. See Appendix C for more details.

Plan ID: 701
Plan Name: SPAP for 126-150% of FPL. This plan effective July 1, 2006. Plan provides co-pay reimbursement for drugs covered by Medicare D. It applies when the participant’s income is 136% through 150% of the Federal Poverty Level. As with plans 012, 700, and 712, this plan allows for a $2.40/$6.00 co-pay reimbursement. See Appendix C for more details.

Plan ID: 999
Plan Name: QMB, QDWI, SLMB/SPAP - This plan provides $2.40/$6.00 co-pay reimbursement for drugs covered by Medicare D through either plan 700 or plan 701. Related Plan:

Medicaid: 999 - Prisoners, QMB, QDWI, SLMB and PACE

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