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