AlohaCare Advantage Plus (HMO SNP)

1. Appointment of Representative: The form must be signed by you and the person you want to act on your behalf. This person can file a grievance, appeal or coverage determination for you. You may give any person permission to act on your behalf by filling out this form and sending it to us. 
2. Request for Medicare Prescription Drug Coverage Determination: If your drugs are not covered by AlohaCare Advantage Plus, you can fill out this form to request an exception. By requesting an exception, you are asking us to cover your drug even though it is not on the formulary. 
3. Medicare Re-determination Request: Did AlohaCare Advantage Plus deny your request to cover a drug that is not on our formulary? Fill out this form if you do not agree with our decision and want us to look at it again. Be sure to include additional information on why you feel your drug should be covered.
4. Request for Reconsideration (Appeal) of Medicare Prescription Drug Denial: Request an independent review of AlohaCare Advantage Plus' re-determination decision on your drug coverage. 
5. Coordination of Benefits/Direct Claim: Submit this form with your receipts to help pay for out-of-pocket drug costs.
6. Medicare Part D Coverage Determination Request: If your drugs are not covered by AlohaCare Advantage Plus, your doctor can also request an exception by filling out this form. By requesting an exception, your doctor is asking us to cover your drug even though it is not on our formulary.
7. Authorization to Disclose Protected Health Information: Give AlohaCare Advantage Plus permission to release your private health information to another person that you designate.