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Medicare : Frequently Asked Questions

Have questions about your health plan? 'Ohana wants to make it easy for you to find answers. Below are some commonly asked questions from our members along with the respective answers. If you have a question that isn’t listed here, or if you need any information regarding your ‛Ohana health plan coverage, please contact us.



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. That 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 HMO POS plan?

A: A Medicare Advantage HMO POS 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: Where can I get information about basic Medicare terms?

A: We want you to make an informed decision about your Medicare health plan. That’s why we created a glossary to help you understand many commonly used Medicare terms.

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 an ‘Ohana Medicare Advantage Plan?

A: You can enroll or make a plan change into an 'Ohana Plan three months before to three months after the month you turn 65. This is your Initial Coverage Election Period. You can also enroll during the Open Enrollment Period (October 15 - December 7 of every year), in which your new coverage would be effective January 1. There are also exceptions throughout the year that may allow you to make plan changes outside of the Open Election Period. Contact us for more information.


What's Covered


Q: How do members get permission to receive services?
A: Members can get service authorizations from their primary care provider (PCP) or from specialists they were referred to by their PCP. Please review this list of authorization and referral requirements to see which services require authorization.


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 HMO POS plans cover services that Medicare does not consider medically necessary?

A: An HMO or HMO POS 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. Our Customer Service representatives are ready to answer questions.

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 other options for Medicare coverage in your area.

Q: What if I need to talk to a nurse?

A: One of the perks of being an ‛Ohana member is our 24-hour Nurse Advice Line. Our nurses will give you answers to your medical questions and help you decide whether or not to see your doctor or go to the emergency room. Nurses are available 24 hours a day, 7 days a week.  Just call the number on the back of your member identification (ID) card.


Top of Questions & Answers


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, unless it is covered by Medicaid or another third party. If you meet certain eligibility requirements for both Medicare and Medicaid, your Part B premium may be covered in full.


Top of Questions & Answers

Prescription Drug Coverage

Q: One of the prescriptions I usually take isn't on the ‘Ohana formulary. What should I do?

A: Contact us and we can look up your prescription to see if it's part of our formulary. When you call, one of our representatives may suggest an alternative medication.  Please check with your doctor to see if that alternative would work for you.  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 can ask us to pay you back by completing our Direct Member Reimbursement Formpdf and mailing it back to us. Please make sure that you keep a copy of the form and the receipts for your records. We will mail you a letter within 7 to 10 days with our decision concerning your request for reimbursement.

Q: What if I mailed my request for ‘Ohana to pay for my prescriptions, but I have not received any information?

A: If after 10 days, you have not received your letter with our decision, please contact us. We will provide you information, including whether we received your request.

Q: What prescriptions are covered by ‘Ohana?

A: ‘Ohana covers both brand-name and generic prescription drugs. The federal government has created guidelines for the types of drugs we must cover, along with a minimum standard of benefits. You can review our full list of our covered prescription drugs either by using our search a drug tool or you can download a comprehensive formulary.

Q: Where can I fill my prescriptions?

A: You can use your 'Ohana ID card at any of our network pharmacies. Some of our network pharmacies (retail and mail-service) offer preferred cost-sharing. By filling your prescription at a network pharmacy (retail or mail-service) that offers preferred cost-sharing, your co-payment could be lower.  Network pharmacies that offer preferred cost-sharing include Duane Reade, Kmart, Kroger, Sam’s Club, Walgreens, and Wal-Mart. Use our pharmacy search tool to find both preferred and network pharmacies in your area.

Q: Does my 'Ohana Prescription Drug Plan cover medications filled by an out-of-network pharmacy?

A: A network pharmacy is a pharmacy that has a contract with the plan to provide your covered prescription drugs.


Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available. There are certain circumstances in which we could cover prescriptions filled at an out-of-network pharmacy such as traveling or a medical emergency.  Review our Evidence of Coverage for more information about filling your prescriptions at an out-of-network pharmacy.  If you must use an out-of-network pharmacy, you generally have to pay the full cost (rather than your normal share of the cost) when you fill your prescription. You can ask us to pay you back for our share of the cost by completing a Direct Member Reimbursement Formpdf


Q: I'd like to get a three-month supply of my drugs. Is that possible?

A:  You can get an extended day supply of most drugs when you use a pharmacy that offers extended day supplies. Please call your pharmacy beforehand to confirm they offer a three-month supply.  


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. To reduce your drug cost, consider using preferred generics, which are usually less expensive than brand-name drugs.  

Q: I get some of my prescriptions through Medicare Part B. Will anything change?

A: You'll continue to get them through Part B. Prescriptions received as part of a physician's services, due to surgery, along with certain Part B 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. If you're eligible, you can get assistance with paying your deductibles, monthly plan premiums and co-payments. 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.

Q: I filled my prescription at a CVS Pharmacy and was charged the standard retail cost-sharing.  I thought CVS offers preferred cost-sharing.

A: CVS offers preferred cost-sharing for their mail-service.  Prescriptions filled at a CVS retail location will be charged the standard cost-sharing rate.

Q: I filled my prescription through Walgreens Mail Service and was charged a standard cost-sharing rate.  I thought Walgreens offers preferred cost-sharing.

A: Walgreens retail pharmacies offer preferred cost-sharing.  Walgreens mail-service offers standard cost-sharing.

Q: I'm planning on taking a trip to the US Mainland. Where can I have my prescriptions filled?

A: WellCare has network retail pharmacies throughout the United States. Use our Pharmacy Directory to locate a network pharmacy in the area in which you will be traveling or call Customer Service for assistance.

Top of Questions & Answers

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Last modified: 07/06/2015

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