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Here are a variety of pharmacy-related links and tools for your use.

Medication Guide/Formulary

Providers can search through a list of prescription drugs covered by our pharmacy plan:

For any drugs not listed, you may request that we consider it for inclusion by submitting medical justification in writing to:

‘Ohana Health Plans, Clinical Pharmacy Department
Director of Formulary Services
Pharmacy and Therapeutics Committee
PO Box 31577
Tampa, FL 33631-3577

Coverage Determination

The coverage determination process enables providers to request an addition or exception.

Medication Appeals

Appeal a coverage determination decision.

Nhà Thuc Chuyên Khoa AcariaHealth

This service is available at no additional cost to patients undergoing treatment for long-term, life-threatening or rare conditions.


Nhà Thuốc

This policy provides a list of drugs that require step therapy. Step therapy is when we require the trial of a preferred therapeutic alternative prior to coverage of a non-preferred drug for a specific indication.

Drug Prior Authorization Requests Supplied by the Physician/Facility

Fill out and submit this form to request prior authorization (PA) for your Medicare prescriptions.

Fill out and submit this form to request an appeal for Medicare medications.

Below are the most commonly prescribed medications that were on the 2018 formulary and their preferred 2019 alternatives.

Pharmacy Clinical Policies

Hydroxyprogesterone caproate (Makena®/compound) is a progestin.

Eculizumab (Soliris®) is a complement inhibitor.

Mogamulizumab-kpkc (Poteligeo®) is a CC chemokine receptor type 4 (CCR4)-directed monoclonal antibody.

The following are factor VIII products requiring prior authorization: human – Hemofil M®, Koate-DVI®; recombinant – Advate®, Adynovate®, Afstyla®, Eloctate®, Esperoct®, Helixate FS®, Jivi®, Kogenate FS®, Kogenate FS with Vial Adapter®, Kogenate FS with Bio-Set®, Kovaltry®, NovoEight®, Nuwiq®, Obizur®, Recombinate®, ReFacto®, Xyntha®, and Xyntha® Solofuse™.

Factor VIIa, recombinant (NovoSeven® RT) and coagulation factor VIIa (recombinant)-jncw (SevenFact®) are coagulation factors.

AbobotulinumtoxinA (Dysport®) is an acetylcholine release inhibitor and a neuromuscular blocking agent.

IncobotulinumtoxinA (Xeomin®) is an acetylcholine release inhibitor and a neuromuscular blocking agent.

OnabotulinumtoxinA (Botox®) is an acetylcholine release inhibitor and a neuromuscular blocking agent.

RimabotulinumtoxinB (Myobloc®) is an acetylcholine release inhibitor and a neuromuscular blocking agent.

Eteplirsen (Exondys 51™) is an antisense oligonucleotide.

Ocrelizumab (Ocrevus™) is a CD20-directed cytolytic antibody.

Cerliponase alfa (Brineura®) is a hydrolytic lysosomal N-terminal tripeptidyl peptidase.

Edaravone (Radicava™) is a member of the substituted 2-pyrazolin-5-one class that acts as a free-radical scavenger of peroxyl radicals and peroxynitrite.

Testosterone pellet (Testopel®) is an implantable androgen. Testosterone undecanoate (Jatenzo®) is an oral androgen.

Tisagenlecleucel (Kymriah™) is a CD19-directed, genetically modified, autologous T-cell immunotherapy.

Axicabtagene ciloleucel (Yescarta™) is a CD19-directed, genetically modified, autologous T-cell immunotherapy.

Voretigene neparvovec-rzyl (Luxturna™) is an adeno-associated virus vector-based gene therapy.

Ibalizumab-uiyk (Trogarzo™) is a CD4-directed post-attachment human immunodeficiency virus type 1 (HIV-1) inhibitor.

Patisiran (Onpattro™) is a double-stranded small interfering ribonucleic acid, formulated as a lipid complex for delivery to hepatocytes.

Ravulizuamb-cwvz (Ultomiris®) is a complement inhibitor.

Caplacizumab-yhdp (Cablivi®) is a von Willebrand factor (vWF)-directed antibody fragment.

Elapegademase-lvlr (Revcovi®) is a recombinant adenosine deaminase.

Onasemnogene abeparvovec (Zolgensma®) is an adeno-associated virus (AAV) vector-based gene therapy.

Trientine (Syprine®) is a chelating agent.

Crizanlizumab-tmca (Adakveo®) is a selectin blocker.

Golodirsen (Vyondys 53TM) is an antisense oligonucleotide.

Inebilizumab-cdon (Uplizna ™ ) is an anti-CD19 monoclonal antibody.

Belantamab mafodotin (Blenrep®/™ ) is an anti-B-cell maturation antigen (BCMA) monoclonal antibody and microtubule inhibitor conjugate.

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Access key forms for doing business with 'Ohana Health Plan.

NDC Reporting Guidelines

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Last Updated On: 5/7/2021
Medicare Members: Your materials are on the way! We realize you may be waiting to receive some plan materials and we apologize for any delays. Did you know you can go online to our member portal to view Member materials, review your benefits, request or download an ID card, or choose a physician (when applicable)? Log in or register today!
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