Medicare : Member Materials
Thank you for being an 'Ohana member. On this page, you will be able to quickly find member materials, forms, flyers and brochures.
Plan Information and Materials
Enrollment Form 
Evidence of Coverage
Summary of Benefits
Comprehensive Formulary and Formulary Updates
Plan Ratings
HealthStuff (Over-The-Counter) Catalog 
Routine Dental Brochure 
Transportation Flyer 
Low Income Subsidy (LIS) Premium Summary Chart 
Explanation of Benefits (sample) 
Part D Transition Letter (sample)
Part D Transition Policy 
Payment and Reimbursement Forms
'Ohana Direct Member Reimbursement 
Electronic Funds Transfer 
HealthStuff (Over-The-Counter) Item Reimbursement 
Authorization Forms
Appointment of Representative
HIPAA Release of Information
HIPAA Release of Information Revocation 
Pharmacy and Other Forms
Exactus Pharmacy Solutions Enrollment Form 
Exactus Pharmacy Solutions Prescription Order Form 
Online Form: Request for Medicare Prescription Drug Coverage Determination (Provider & Member)
Request for Medicare Prescription Drug Coverage Determination 
- Providers and members should fax form to 1-888-877-8239
'Ohana Injectable Infusion 
Online Form: Request for Redetermination of Medicare Prescription Drug Denial (Appeal)
Request for Redetermination of Medicare Prescription Drug Denial (Appeal) 
Medicare Prescription Drug Coverage and Your Rights 
H2491_HI018431_WCM_WEB_ENG CMS Approved MMDDYYYY
Pending CMS Approval
Last modified: 04/09/2012



