Member Documents

AlohaCare Advantage Plus (HMO SNP)

Click here to request hard copies of any of these materials. Hard copies are free upon request and will be provided within five business days.



2020 Annual Notice of Changes

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

2020 Evidence of Coverage

Evidence of Coverage gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2020. It explains how to get coverage for the health care services and prescription drugs you need.

2020 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".

2020 Provider and Pharmacy Directory

This directory provides a list of AlohaCare Advantage and AlohaCare Advantage Plus’ (HMO SNP) network providers.

2020 Comprehensive Formulary

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.

2020 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.

2020 Prior Authorization Criteria

This document discusses the need for prior authorization for certain drugs that are on the formulary or drugs that are not on the formulary.

2020 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. are on the formulary or drugs that are not on the formulary.

2020 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.

Prescription Drug Reimbursement Form

This form allows you to file a claim if you paid out of pocket for a prescription. All claims are subject to review and approval. Please remember to always show your member ID card before picking up a prescription.

Injury/Illness Form

Please complete this form if your injury or illness happened at work or as a result of an automobile accident.

H5969_WEB40062002 Accepted