AlohaCare Advantage Plus (HMO SNP)
Your Medical Benefit
As a member of AlohaCare Advantage Plus, you receive help based on your level of Medicaid eligibility. You must continue to pay your Part B premium. As a member of AlohaCare Advantage Plus, your Part B premium is paid for by the State. In many cases, you receive full coverage and pay nothing for your medical costs. Some of your benefits are listed below:
- $25.50 monthly MA-PD premium. As a member of AlohaCare Advantage Plus, your Part B premium is covered by the State.
- 0% or 20% of the cost for each Primary Care Physician (PCP) visit for Medicare-covered benefits*
- 0% or 20% of the cost for each Specialist visit for Medicare-covered benefits*
- $0 - $2.50 co-pay for each generic drug*
- 0% or 20% co-pay or of the cost for certain preventive services including: bone mass measurement, colorectal screening exams, immunizations, mammograms, pap smears and pelvis exams and prostate cancer screening exams*
- $1000 limit for emergency services outside the U.S. every year**
**All cost sharing is based on your level of Medicaid eligibility. Contact Medicaid for details.
**Benefit conditions and limitations apply. Be sure to look at your Summary of Benefits and Evidence of Coverage for more information on your plan benefits.
If you have any questions about your medical coverage, including grievances, coverage determinations (including exceptions) and the appeals process, please refer to Chapter 9 of your Evidence of Coverage (EOC) or contact AlohaCare.
Primary Care Physician (PCP)
As a member of AlohaCare Advantage Plus, you have chosen a PCP to help manage your health care needs. You should see your PCP first for all routine care. Your PCP is responsible for referring you to specialists. You must use plan providers except in emergent or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor AlohaCare Advantage Plus will be responsible for the costs.
Prior Authorizations
For certain medications and medical services, you must first receive approval from AlohaCare Advantage Plus before the medication and medical services are covered under your plan. You or your doctor can initiate the authorization request to AlohaCare Advantage Plus. We will notify you and your doctor of our decision. In some cases, your medications and medical services are covered with a prior authorization.
Member Service Navigator
As an AlohaCare Advantage Plus member, you receive personal help from our Member Service Navigators. Here is how our Member Service Navigators make sure you get the health care you need:
- Helping you choose your PCP
- Setting up doctor’s appointments
- Going with you to your doctor appointments
- Making sure you get the prescriptions you need
- Answering questions about our plan and Medicaid coverage
Low Income Subsidy or “Extra Help”
If you have limited income and resources, you may be able to get Extra Help. Generally, your premium will be lower once you receive Extra Help from Medicare.
To see how much your premium would be if you qualified for Extra Help, click on the Low Income Premium Table.
If you qualify for Extra Help, you get help paying for your monthly premium, yearly deductible, prescription co-insurance and co-payments and experience no gap in coverage. Premiums include coverage for both medical services and prescription drug coverage. This does not include any Medicare Part B premium you may have to pay.
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for getting Extra Help, call:
- 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7days a week;
- The Social Security Office at 1-800-722-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
- Your State Medicaid Office.
People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for seventy-five percent of drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.
How do I request an exception to the AlohaCare Advantage Plus Formulary?
You, your prescribing doctor, or someone you name, may ask AlohaCare Advantage Plus to make an exception to our Part D coverage rules in a number of situations.
- You may ask us to cover your Part D drug even if it is not on our formulary. Excluded drugs cannot be covered by a Part D plan.
- You may ask us to waive coverage restrictions or limits on your Part D drug. For example, for certain Part D drugs, we limit the amount of the drug that we will cover. If your Part D drug has a quantity limit, you may ask us to waive the limit and cover more.
- You may ask us to provide a higher level of coverage for your Part D drug. If your Part D drug is contained in our Brand/Tier 2 tier, you may ask us to cover it at the cost-sharing amount that applies to drugs in the Generic/Tier 1 tier instead. This would lower the co-insurance/co-payment amount you must pay for your Part D drug. Please note, if we grant your request to cover a Part D drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Generally, we will only approve your request for an exception if the alternative Part D drugs included on the formulary or the Part D drug in the preferred tier would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
If your doctor is requesting an exception, he/she can submit the request in writing or by completing the
Medicare Part D Coverage Determination Request Form. Your doctor should submit additional information, such as medical records, to help us make a decision. The request can be submitted by mail or fax to:
AlohaCare Advantage Plus
Customer Service
1357 Kapiolani Blvd. Suite 1250
Honolulu, HI 96814
Fax #: (808) 973-0726
You can also verbally request an expedited or standard exception by calling our Customer Service Department at 973-6395 or toll-free at 1-866-973-6395 from Oahu, Neighbor Islands or Mainland.
If we approve your exception request, our approval is valid for the remainder of the plan year, so long as your doctor continues to prescribe the Part D drug for you and it continues to be safe for treating your condition. If we deny your exception request, you may appeal our decision.
Note: If we approve your exception request for a Part D non-formulary drug, you cannot request an exception to the co-payment or co-insurance amount we require you to pay for the drug.
Rights upon Disenrollment
Ending your membership with AlohaCare Advantage Plus may be voluntary (your own choice) or involuntary (not your own choice). You might leave our plan because you have decided that you want to leave. There are also limited situations where we are required to end your membership. For example, if you move permanently out of the geographic service area we cover. We cannot ask you to leave our plan because of your health.
If you leave our plan, it may take some time for your membership to end. While you are waiting for your membership to end, you are still a member and must continue to get your care and/or prescription drugs as usual through our plan.
You have the right to make a complaint if we end your membership in our plan. If we end your membership in our plan we will tell you our reasons in writing and explain how you may file a complaint against us if you want to.
Contact Us
If you have any questions or for more information on your benefits, call AlohaCare Advantage Plus Customer Service from Oahu at 973-6395 or toll-free at 1-866-973-6395 from the Oahu, Neighbor Islands or Mainland, 8 a.m. to 8 p.m., Monday through Friday, or visit us 8 a.m. to 5 p.m., Monday through Friday. (TTY/TDD users can call 1-877-447-5990.) Our office is located at 1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814.
Click on this link for information regarding your AlohaCare Advantage Plus Part D Prescription Drug Benefit.