Member Documents
MATERIALS
AlohaCare Advantage Plus (HMO D-SNP)
Click here to request hard copies of any of these materials. Hard copies are free upon request and will be provided within three business days.
Annual Notice of Changes | Annual Notice of Changes tells you about the changes to the plan's costs and benefits for the upcoming year.
|
Evidence of Coverage | Evidence of Coverage gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2025. It explains how to get coverage for the health care services and prescription drugs you need. |
Summary of Benefits | Summary of Benefits tells you some features of our plan. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please call AlohaCare Advantage Plus (HMO D-SNP) and ask for the "Evidence of Coverage".
|
Provider and Pharmacy Directory | This directory provides a list of AlohaCare Advantage Plus’ (HMO D-SNP) network providers.
|
Comprehensive Formulary | A formulary is a list of covered drugs selected by AlohaCare Advantage Plus in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. The formulary will list the drugs that are covered under your Medicare and Medicaid benefits. |
Prior Authorization Criteria | This document discusses the need for prior authorization for certain drugs that are on the formulary.
|
Step Therapy Drugs | AlohaCare requires you to first try one drug to treat your medical condition before we will cover another drug for that condition. |
AlohaCare Advantage (HMO D-SNP)
Annual Notice of Changes | Annual Notice of Changes tells you about the changes to the plan's costs and benefits for the upcoming year. |
Evidence of Coverage | Evidence of Coverage gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2025. It explains how to get coverage for the health care services and prescription drugs you need. |
Summary of Benefits | Summary of Benefits tells you some features of our plan. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please call AlohaCare Advantage Plus (HMO D-SNP) and ask for the "Evidence of Coverage". |
Provider and Pharmacy Directory | This directory provides a list of AlohaCare Advantage network providers.
|
Comprehensive Formulary | A formulary is a list of covered drugs selected by AlohaCare Advantage in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program.
|
Prior Authorization Criteria | This document discusses the need for prior authorization for certain drugs that are on the formulary. |
Step Therapy Drugs | AlohaCare requires you to first try one drug to treat your medical condition before we will cover another drug for that condition. |
Other AlohaCare Medicare Plan Materials
Star Rating | The Medicare Program rates all health and prescription drug plans each year, based on a plan's quality and performance. Medicare Plan Ratings help you know how good a job our plan is doing. |
| Use this form to request reimbursement for covered medications purchased at retail cost. Complete one form per member.
|
| This form lets you choose who to share information with and what information to share. |
| Complete and mail in this form to sign up to have medicine you take on a regular basis to be delivered to your home. |
| Non Discrimination and Notice of Availability | We have free interpreter services to answer any questions you may have about our health or drug plan. |
Non-Emergent Medical Transportation: Transdev | Travel arrangements can be made through Transdev. Click here ↗ to visit the Transdev site. |
| This notice describes how medical information about you may be used and shared and obtained. |
| AlohaCare Advantage and AlohaCare Advantage Plus have a limited annual benefit that covers emergency services you may need while traveling outside of the U.S. |
AlohaCare Medicare Plans Model of Care Program | AlohaCare's Medicare Plans are dual-eligible Special Needs Plans (D-SNP). One advantage for members of SNP plans is the D-SNP Model of Care, which is an interdisciplinary care coordination program.
The following are links to resources related to the SNP Model of Care. |
| Please complete this form if your injury or illness happened at work or as a result of an automobile accident. |
Health Risk Assessment | |
H5969_WEB40062601_M