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Member Documents

AlohaCare Advantage Plus (HMO SNP)

Click here to request hard copies of any of these materials.



2017 Annual Notice of Changes
Annual Notice of Changes tells you about the changes to the plan's costs and benefits for the upcoming year.

2017 Evidence of Coverage
Evidence of Coverage gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2017. It explains how to get coverage for the health care services and prescription drugs you need.

2017 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 SNP) and ask for the "Evidence of Coverage".

2017 Provider & Pharmacy Directory (updated 8/2017)
This directory provides a list of AlohaCare Advantage and AlohaCare Advantage Plus’ (HMO SNP) network providers.

2017 Comprehensive Formulary (updated 8/2017)
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.

2017 Plan 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.

2017 Prior Authorization Criteria
This document discusses your need prior authorization for certain drugs that are on the formulary or drugs that are not on the formulary

2017 Step Therapy Criteria
This document tells you the list of drugs that have step therapy requirements. AlohaCare requires you to first try one drug to treat your medical condition before we will cover another drug for that condition. 

2017 Multi-Language Insert

We have free interpreter services to answer any questions you may have about our health or drug plan.


Privacy Notice
This notice describes how medical information about you may be used and shared and obtained.
Coordination of Benefits/Direct Claim
Submit this form with your receipts to help pay for out-of-pocket drug costs. 

World-Wide Benefit Reimbursement Form
AlohaCare Advantage Plus has a limited annual benefit that covers emergency services you may need while travelling outside of the U.S.

AlohaCare Advantage Plus (HMO SNP) Model of Care Program
AlohaCare Advantage Plus is a dual-eligible Special Needs Plan (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.

H5969_400619_17 Approved

Last updated 8/1/2017. Please contact AlohaCare for more information.