Medicare : Frequently Asked Questions
General
What's Covered
Costs
Prescription Drug Coverage
General
Q: What is a Medicare Advantage HMO plan?
A: A Medicare Advantage HMO plan is offered by a private company that contracts with Medicare to provide you with all your Medicare Part A (hospital) and Part B (medical) benefits. It is a health maintenance organization, or HMO. The means it provides care through a network of providers. Care is coordinated through the primary care physician (PCP), who may refer people to specialists as needed. Referrals are generally required to see specialists.
Q: What is a Medicare Advantage HMOPOS plan?
A: A Medicare Advantage HMOPOS also provides care through a network of providers. However, it includes a point of service (POS) feature, which allows members to receive health care services outside of the network with authorization from the plan, although use of providers within the network is encouraged.
Q: What is a network?
A: Network providers are the doctors and other health care professionals, medical groups, hospitals and other health care facilities that have an agreement with us to deliver covered services to members in our plan. The providers in our network generally bill us directly for care they give you. When you see a network provider, you usually pay only your share of the cost for their services.
Q: Should I still keep my red, white and blue Medicare Card?
A: Yes. However, as long as you are a member of our plan you must not use your red, white and blue Medicare card to get covered medical services (with the exception of clinical research studies and hospice services). Keep your red, white, and blue Medicare card in a safe place in case you need it later. Here’s why this is so important: If you get covered services using your red, white and blue Medicare card instead of using our membership card while you are a plan member, you may have to pay the full cost yourself. If your 'Ohana ID card is damaged, lost or stolen, contact us right away and we will send you a new card.
Q: If I don't like my 'Ohana plan, can I go back to Original Medicare?
A: Of course. You don't lose your Medicare benefits when you join our plan. However, there are limits on when and how often you can change your Medicare Advantage plan. Contact us to find out more.
Q: When can I enroll or make a plan change into a WellCare Medicare Advantage Plan?
A: You can enroll or make a plan change into a WellCare Plan three months before to three months after the month you turn 65. This is your Initial Enrollment Period. You can also enroll during the Annual Enrollment Period (October 15 - December 7 of every year), in which your new coverage would be effective January 1st. There are also exceptions throughout the year that may allow you to make plan changes outside of the Annual Enrollment Period. Contact us for more information.
What's Covered
Q: Will I have the same coverage as I do with Original Medicare?
A: Our plans are in place of Original Medicare (except clinical research studies and hospice services) and some offer extra benefits such as routine dental, routine hearing, routine vision and prescription drug coverage. If you have questions about whether your plan will pay for specific services, please read the Summary of Benefits or Evidence of Coverage for more information.
Q: Can I receive emergency care?
A: You have the right to emergency care, when needed, anywhere in the United States and without pre-approval from us. Please read the Evidence of Coverage or contact us for details.
Q: Do HMO or HMOPOS plans cover services that Medicare does not consider medically necessary?
A: An HMO or HMOPOS plan is not required to pay for services that are not medically necessary under Medicare. However, 'Ohana plans do pay for additional benefits not covered by Original Medicare. If you receive a service that is not covered by our plan, you are responsible for the cost of that service. If you are not sure whether a service is covered, you have the right to call us and ask for an advance decision.
Q: What do I need to do to get care?
A: Our plans work just like traditional health insurance. Just show your 'Ohana Member ID card (instead of your Medicare card) at the doctor's office. You may have a co-payment due at that time.
Q: What happens if my doctor is not familiar with 'Ohana Plans?
A: If your doctor or health care provider would like more information about 'Ohana, contact us.
Q: Can 'Ohana ever drop my coverage?
A: Once you're enrolled, you cannot be disenrolled for a medical condition. However, if you move out of our service area or commit fraud, 'Ohana reserves the right to disenroll you. Please read the Evidence of Coverage for complete details. All Medicare Advantage plans commit to their members for a full year. Each year, 'Ohana decides whether to continue a plan for another year. Even if a Medicare Advantage Plan is discontinued at the end of a benefit year, you will not lose Medicare coverage. If your plan is discontinued at the end of a benefit year, 'Ohana must notify you in writing at least 60 days before your coverage ends. The letter will explain your options for other Medicare coverage in your area.
Costs
Q: Do I still have to pay my Medicare Part B premium?
A: Yes. When you join an 'Ohana plan, you must continue to pay your Medicare Part B premium. If you meet certain eligibility requirements for both Medicare and Medicaid, your Part B premium may be covered in full.
Prescription Drug Coverage
Q: One of the prescriptions I usually take isn't on the 'Ohana formulary. What should I do?
A: Don't worry. It is likely that we cover your drug or have an alternative for you. Contact us and we can look up your prescription to see if its part of our formulary. When you call, the pharmacy representative may also suggest a preferred brand or preferred generic equivalent of your prescription. By using these, you can save substantially. If your doctor feels that you need to take a certain brand name prescription drug that isn't covered, we have a review process in place that may allow you to do this. Read our Part D Transition Policy 
for what to do if your medication isn't covered by the plan.
Q: What if I have to pay cash for my prescription because I do not have my 'Ohana ID card?
A: You will need to request a reimbursement from 'Ohana by completing our Direct Member Reimbursement Form and mailing it back to us. Please make sure that you keep a copy of the form and the receipts for your records.
Q: How will I know if 'Ohana is going to pay me for the prescriptions when I did not have my 'Ohana ID card?
A: We will send you a letter that informs you of our decision concerning the request for payment of your prescriptions. You should expect to receive this letter within 7 to 10 business days.
Q: What if I mailed my request for 'Ohana to pay for my prescriptions, but I have not received any information?
A: Please contact us. We will provide you information, including whether or not we received your request.
Q: What prescriptions are covered by 'Ohana?
A: Brand-name and generic prescription drugs are covered by 'Ohana. The federal government has created guidelines for the types of drugs that must be covered, along with setting a minimum standard of benefits. You can review our full list of our covered prescription drugs either by using our search tool or you can download a comprehensive formulary.
Q: Can I use my 'Ohana ID card at a lot of different pharmacies?
A: You can use your 'Ohana ID card at any of our 60,000 network pharmacies. Some our of network pharmacies include popular retail stores such as Walgreens, CVS, Rite Aid, Target, Walmart, and Costco. Use our pharmacy search tool to find a pharmacy in your area.
Q: Can I get prescriptions through a mail service?
A: Yes, Exactus Pharmacy Solutions is Ohana's preferred mail service provider that can deliver your prescriptions right to your door. In fact, you may save 17%* on a 3-month supply of maintenance medications when using our preferred mail service provider. Best of all, using Exactus can help you stay out of the Medicare coverage gap. Learn more about Exactus Pharmacy Solutions and the benefits they offer.
*This savings occurs when you use Exactus Pharmacy Solutions, Ohana's preferred mail service pharmacy as compared to using a non-preferred mail service pharmacy.
Q: I'd like to get a 3-month supply of my drugs. Is that possible?
A: You can get a 3-month supply of most drugs (with the exception of drugs in our Specialty Tier) when you use a pharmacy that contracts to offer 3-month supplies. If you use Ohana's preferred mail service provider, Exactus Pharmacy Solutions, you may save 17%* on a 3-month supply of maintenance medications. Learn more about Exactus Pharmacy Solutions.
*This savings occurs when you use Exactus Pharmacy Solutions, WellCare's preferred mail service pharmacy as compared to using a non-preferred mail service pharmacy.
Q: What is Exactus Pharmacy Solutions?
A: Exactus (formerly known as WellCare Specialty Pharmacy) is a WellCare company and a licensed pharmacy registered in all 50 states. As a licensed pharmacy, Exactus can service members regarding their pharmaceutical needs and deliver medicationst and supplies to our members living throughout the country for their specialty and mail service needs.
Q: Can I get drugs from another country through 'Ohana?
A: No. Please read the Evidence of Coverage for more information.
Q: Can your plan refuse me coverage if I take a lot of prescriptions?
A: As long as you are eligible, 'Ohana can not refuse to offer you coverage. You should also consider using generic drugs, which may be less expensive than brand drugs.
Q: I get some of my prescriptions through Medicare Part B. Will anything change?
A: You'll continue to receive them through Part B. Prescriptions received as part of a physician's services or because of surgery (as well as certain prescription drugs) are covered through Part B. Please contact us if you need more information.
A: You'll continue to receive them through Part B. Prescriptions received as part of a physician's services or because of surgery (as well as certain prescription drugs) are covered through Part B. Please contact us if you need more information.
Q: What if I'm on a limited income or cannot afford my prescription drugs?
A: You may qualify for extra help from the federal government—and if you're eligible, this assistance could really reduce the cost of your drugs. Learn more about Extra Help.
Q: I was at the pharmacy and was told I do not have coverage. What should I do?
A: Please contact us.
H2491_HI018431_WCM_WEB_ENG CMS Approved MMDDYYYY
Pending CMS Approval
Last modified: 04/09/2012
