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Conditions and Limitations

There are conditions that apply to enrolling (and being enrolled) in our Medicare Advantage Plans. Please make sure to read this section carefully to learn more about your Medicare Advantage coverage and the rules that apply.

  • 'Ohana Health Plan is a Medicare Advantage organization with a Medicare contract. Enrollment in WellCare (HMO) depends on contract renewal.
  • To be eligible, you must be entitled to Medicare Part A and enrolled in Medicare Part B, live in the plan's service area, and not have End-Stage Renal Disease (ESRD), with limited exceptions.
  • Network pharmacies include retail, mail service, specialty, long-term care, home infusion and Indian Health Service/Tribal/Urban Indian Health Program (I/T/U) pharmacies. To obtain names and addresses of 'Ohana's network pharmacies, use the pharmacy search tool or contact us.
  • You must use network pharmacies to access your prescription drug benefit, except under non-routine circumstances (e.g., emergencies) when you cannot reasonably use network pharmacies. Quantity limitations and restrictions may apply.
  • Non-Point-of-Service Plans: You must use plan providers except in emergency or urgent care situations, or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers, neither Medicare nor 'Ohana will be responsible for the costs. (Does not apply to PPO plans.)
  • Point-of-Service Plans: With the exception of emergencies, urgent care and out-of-area renal dialysis, it may cost more to get care from out-of-network providers.
  • You can only be in one Medicare Advantage Plan at a time. If you are currently in a Medicare Advantage or Prescription Drug Plan, your enrollment in 'Ohana will end that enrollment. Enrollment in this plan is generally for the entire year. Once you enroll, you may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: you may make changes Oct. 15-Dec. 7 of every year), or under certain special circumstances.
  • If you have qualified for additional assistance with your Medicare Prescription Drug Plan costs, the amount of your premium and cost at the pharmacy will be less. Once you have enrolled in 'Ohana, Medicare will tell us how much assistance you are receiving, and we will send you information on the amounts you will pay.
  • If you decide to switch to premium withhold or move from premium withhold to direct bill, it could take up to three months for it to take effect and you will remain responsible for payment of those premiums during that time.
  • By law, 'Ohana can choose not to renew our contract with CMS and CMS may also refuse to renew the contract, resulting in a termination or non-renewal. This may result in termination of your enrollment in the plan. Additionally, 'Ohana may reduce its service area and no longer offer services in the area where you reside.
  • This information is available for free in other languages. Please contact Customer Service for more information.
  • Medicare beneficiaries may also enroll in a plan in this state through the CMS Medicare Online Enrollment Center located at
  • This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year.
  • For a complete list of drugs covered by our plan, please call Customer Service.
  • The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
  • Some plans are available to those who have medical assistance from both the state and Medicare. Premiums, co-pays, coinsurance and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • For full information on 'Ohana Medicare Advantage Plan benefits, please contact us.

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Y0070_WCM_42183E Last Updated On: 10/1/2018