Member Documents
2024 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 tells you about the changes to the plan's costs and benefits for the upcoming year. |
| Evidence of Coverage gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2024. It explains how to get coverage for the health care services and prescription drugs you need. |
| 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". |
| This directory provides a list of AlohaCare Advantage and AlohaCare Advantage Plus’ (HMO D-SNP) network providers. |
Formulary Updates: | 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. |
| This document discusses the need for prior authorization for certain drugs that are on the formulary or drugs that are not on the formulary. |
| 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)
| Evidence of Coverage gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2024. It explains how to get coverage for the health care services and prescription drugs you need. |
| 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". |
| This directory provides a list of AlohaCare Advantage and AlohaCare Advantage Plus’ (HMO D-SNP) network providers. |
Formulary Updates: | 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. |
| This document discusses the need for prior authorization for certain drugs that are on the formulary or drugs that are not on the formulary. |
| 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
| 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. |
| Submit this form with your receipts to help pay for out-of-pocket drug costs. |
| Complete and mail in this form to sign up to have medicine you take on a regular basis to be delivered to your home. |
| Multi-Language Insert | We have free interpreter services to answer any questions you may have about our health or drug plan. |
| Non-Emergent Medical Transportation: IntelliRide | Starting March 1, 2021, IntelliRide will make your travel arrangements. |
| 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 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 | |
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