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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 three business days.

2023 MATERIALS

2023 Annual Notice of Changes	Annual Notice of Changes tells you about the changes to the plan's costs and benefits for the upcoming year.
2023 Evidence of Coverage	Evidence of Coverage gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2023. It explains how to get coverage for the health care services and prescription drugs you need.
2023 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".
2023 Provider and Pharmacy Directory	This directory provides a list of AlohaCare Advantage and AlohaCare Advantage Plus’ (HMO SNP) network providers.
2023 Comprehensive Formulary Monthly changes: February 2023 March 2023	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.
2023 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.
2023 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.
2023 Step Therapy Drugs	AlohaCare requires you to first try one drug to treat your medical condition before we will cover another drug for that condition.
COORDINATION OF BENEFITS/DIRECT CLAIM	Submit this form with your receipts to help pay for out-of-pocket drug costs.
CarelonRx Home Delivery Mail Service Order Form	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.

Privacy Notice	This notice describes how medical information about you may be used and shared and obtained.
World-Wide Benefit Reimbursement Form	AlohaCare Advantage Plus has a limited annual benefit that covers emergency services you may need while traveling 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. SNP Model of Care Summary SNP Model of Care Training SNP Model of Care Training Acknowledgment 2017 Stakeholder Communication
Injury/Illness Form	Please complete this form if your injury or illness happened at work or as a result of an automobile accident.

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