Benefits and Covered Services

Member Handbook/Evidence of Coverage (EOC)
The Member Handbook also known as the Evidence of Coverage (EOC) describes in detail the healthcare benefits covered by your plan. (Updated 10/01/2025)
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Summary of Benefits (SOB)
The Summary of Benefits (SOB) is a simplified document that outlines your health benefits and coverage. (Updated 10/01/2025)
English | Spanish | Chinese | Vietnamese | Tagalog | Farsi

Formulary (list of drugs)
The Formulary is list of drugs covered by our plan. (Updated 10/01/2025)
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Provider & Pharmacy Directory
The directory provides a list of network providers and pharmacies who have agreed to provide members with health care services and prescription drugs. (Updated 10/01/2025)
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Enrollment Form
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Pre-enrollment Checklist
English| Spanish | Chinese | Vietnamese | Tagalog | Farsi

As a new Alameda Alliance Wellness member, we created handouts for you to learn more about your health plan, and your plan benefits and covered services. 

Alameda Alliance Wellness Notice of Availability of Language Assistance Services and Auxiliary Aids and Services Aids and Services
Language Assistance Services

Over-the-Counter (OTC) Benefits Catalog
English | Spanish | Chinese | Vietnamese | Tagalog | Farsi

Supplemental Benefit Highlight Flyer
English | Spanish | Chinese | Vietnamese | Tagalog | Farsi

Wellness Programs & Materials Request Form 
English | Spanish | Chinese | Vietnamese | Tagalog | Farsi

Alameda Alliance Wellness partners with Liberty Dental to provide some of your dental benefits.  Dental Services may include, but are not limited to the following:  

Preventive Service 

• Oral Exams – One every year  

Comprehensive Services  

• Restorative 
• One per tooth every seven calendar years  
• Prosthodontics (removable)*  
• Rebases for full or partial dentures covered once every two calendar years  
• Replacement of all teeth & acrylic on cast metal frame covered once every three calendar years  
• Prosthodontics (fixed)*  
• Fixed partial dentures (bridges) – One per tooth every seven calendar years  
• Adjunctive General Services*  
• One consultation is covered every calendar year 

*Prior authorization is required for some services and is the responsibility of your provider. 

To learn more about your plan benefits and covered services, or find a dental provider, please contact:  

Liberty Dental
Toll-Free: 1.888.704.9838
If you cannot hear or speak well, use TTY or call 1.877.855.8039 .
Liberty Dental representatives are available to assist you pacific standard time (PST):
Monday – Friday, 8 am – 8 pm,  from April 1 – September 30
Monday – Sunday (seven (7) days a week), 8 am – 8 pm, from October 1 – March 31
www.libertydentalplan.com

In addition, you also have Medi-Cal dental benefits available to you through the Medi-Cal Dental program. To learn more about Medi-Cal dental benefits and covered services and to locate a Medi-Cal dental provider, please contact:  

Medi-Cal Dental
Toll-Free: 1.800.322.6384
If you cannot hear or speak well, use TTY or call: 1.800.735.2922
Medi-Cal Dental representatives are available to assist you Monday through Friday, 8 am to 5 pm.
smilecalifornia.org

Alameda Alliance Wellness partners with NationsHearing to provide your routine hearing benefits. Alameda Alliance Wellness covers:  

• Hearing aid allowance: up to a $775 hearing aid allowance (per ear) for up to two hearing aids per year. This allowance cannot be rolled over from year to year. You are responsible for any amount beyond this limit.   
• Hearing aid fitting/evaluation: 1 every year  
• Routine hearing exam: 1 every year 

To learn more about your plan benefits and covered services, or to find a hearing provider, please contact: 

NationsHearing
Toll-free: 1.877.408.7542 
If you cannot hear or speak well, use TTY (711)
Member Experience Advisors are available Monday – Sunday (seven (7) days a week, including holidays) 8 am – 8 pm, local time.
For more information, please visit www.alliancewellness.nationsbenefits.com/hearing 

 To learn more about your plan benefits and covered services, please view your Alameda Alliance Wellness Member Handbook.  

Alameda Alliance Wellness members receive a monthly $50 allowance to purchase OTC drug items. This benefit can be used to buy non-prescription items such as cough and cold medicine, vitamins, pain relievers, bandages, and other eligible products. The benefit becomes valid on the first day of every month. Any remaining balance does not carry over to the next month. There may be limitations on the types and quantities of OTC items covered. A prepaid debit card, along with activation instructions will be mailed to you.   

You can use your debit card to purchase OTC products from the catalog in-store at participating pharmacies and retail locations, online, or by phone. 

• In-Store: You can shop for a variety of approved items at CVS, Safeway, Walgreens, Walmart, and more. Go to www.alliancewellness.nationsbenefits.com/hearing to find a participating store near you. 
  Online: Go towww.alliancewellness.nationsbenefits.com/hearing to view a variety of approved products. If this is your first time placing an order online, you will need to create an account by registering on the Benefits Pro Portal or the Benefits Pro app. If you already created an account, simply log in, select your items and when ready click “Checkout.” 
  By Phone: Go to www.alliancewellness.nationsbenefits.com/hearing to find the products you want to order. To place an order by phone, please call 1.877.408.7542 (TTY: 711). Member Experience Advisors are available Monday – Sunday (seven (7) days a week, including holidays) 8 am – 8pm, local time.

 In addition, you also have Medi-Cal OTC benefits. Please visit the Medi-Cal Rx website (www.medi-calrx.dhcs.ca.gov/home/contact) for more information. You can also call the Medi-Cal Rx Customer Service Center at 1.800.977.2273. 

To learn more about your plan benefits and covered services, please view your Alameda Alliance Wellness Member Handbook.  

Alameda Alliance Wellness partners with Vison Service Plan (VSP) to provider your routine eyecare services. Alameda Alliance Wellness covers:   

• One (1) routine eye exam every year 
• Up to $150 for one pair of routine eyeglasses (frames) or contact lenses every two years. Standard lenses (single vision, lined bifocals, or lined trifocals) are covered in full every two years. 

To learn more about your plan benefits and covered services, or to find a vision provider, please contact: 

Vison Service Plan (VSP)
Toll-Free: 1.855.492.9028 
If you cannot hear or speak well, use TTY (711).
VSP representatives are available to assist you Monday – Sunday (seven (7) days a week, 8 am – 8 pm.
For more information, please visit www.vsp.com/advantageonly.  

To learn more about your plan benefits and covered services, please view your Alameda Alliance Wellness Member Handbook.  

Transportation services are offered through our transportation provider, Modivcare. 

To request a ride for services that have been authorized, please call the Alliance Transportation Services toll-free at 1.866.791.4158 at least three (3) business days (Monday-Friday) before your appointment, or as soon as you can when you have an urgent appointment. TTY users can call 1.800.735.2929. Have your Alameda Alliance Wellness member ID card ready when you call. Prior authorization is required for trips greater than 50 miles. 

*Prior authorization is required and is the responsibility of your provider. 

NON-MEDICAL TRANSPORTATION 

This benefit allows for unlimited transportation to medical services by passenger car, taxi, or other forms of public/private transportation. 

Transportation is required for the purpose of obtaining needed medical care covered by Medi-Cal, including travel to dental appointments and to pick up drugs. Transportation for services dually covered by Medi-Cal and Medicare are covered. 

NON-EMERGENCY MEDICAL TRANSPORTATION (MC/NMT)  

This benefit allows for unlimited medical transportation for a service covered by your plan and Medicare. 

This benefit allows for unlimited medical transportation for a service covered by your plan and Medicare. This can include: ambulance, litter van, wheelchair van medical transportation services, and coordinating with para transit. 

 The forms of transportation are authorized when:  

• Your medical provider determines your medical and/or physical condition doesn’t allow you to travel by bus, passenger car, taxicab, or another form of public or private transportation, and prior authorization is required and you’ll need to call your plan to arrange a ride.

To learn more about your plan benefits and covered services, please view your Alameda Alliance Wellness Member Handbook.  

At the Alliance, we and your doctors are here to help you. As your partner in health, we strive to connect you to the right care at the right time. If you have a health concern, please call your doctor any time, 24 hours a day, 7 days a week. 

YOUR DOCTOR  

Call your doctor’s office or clinic for advice. Doctors expect to get phone calls at night or on weekends. They set up their practices to receive your calls at times when they are not open. Your doctor can help you decide if you really need to go to the emergency room, or can give you advice about what to do at home that can get you or your child through the night or weekend. 

NURSE ADVICE LINE  

If you can’t reach your doctor, the nurse line is ready to give you advice, any time, 24 hours a day, 7 days a week.

Please call: 

• Toll-Free: 1.888.433.1876 (TTY: 711) 

Key features of the Nurse Advice Line: 

• No cost for Alameda Alliance Wellness Members.  
• Ready to help 24 hours a day, 7 days a week. 
• Nurses provide advice on topics, such as:  
  • Treatment of common health concerns  
  • Tips on leading a healthy lifestyle  
  • Health screenings and shots  
• Nurses help you decide whether you require emergency or urgent care, or if you should schedule a doctor’s visit.  
• Nurses speak English and Spanish, and use interpreters for other languages.  

Your doctor or the nurse advice line may direct you to an urgent care clinic. Many clinics are open late, on weekends and holidays. To find an urgent care clinic in the Alliance network, please search our online Alliance Provider Directory. 

To view a copy of the Alameda Alliance Wellness Provider and Pharmacy Directory, please click here. 

You can get an annual checkup. This is to make or update a prevention plan based on your current risk factors. We pay for this once every 12 months. 

Note: Your first annual wellness visit can’t take place within 12 months of your Welcome to Medicare visit. However, you don’t need to have had a Welcome to Medicare visit to get annual wellness visits after you’ve had Part B for 12 months. 

Pre-approval (prior authorization)  

For some types of care, your primary care provider (PCP) or specialist will need to ask the Alliance for permission before you get the care. This is called asking for prior authorization, prior approval, or preapproval. It means that the Alliance must make sure that the care is medically necessary or needed. Medically necessary services are reasonable and necessary to protect your life, keep you from becoming seriously ill or disabled, or reduce severe pain from a diagnosed disease, illness or injury. For members under the age of 21, Medi-Cal services includes care that is medically necessary to fix or help relieve a physical or mental illness or condition.  

The following services always need pre-approval (prior authorization), even if you get them from a provider in the Alliance network:  

• Hospitalization, if not an emergency 
• Services out of the Alliance service area, if not an emergency or urgent  
• Outpatient surgery  
• Long-term care  
• Community Supports 
• Specialized treatments  
• Medical transportation services when it is not an emergency. Emergency ambulance services do not require pre-approval.  
• Outpatient diagnostic and radiology services, minimally invasive or invasive, such as CT scans, MRIs, cardiac catheterization, PET  
• Home Health Care, including skilled nursing, nursing aides, rehabilitation therapies, and social workers  

The Alliance contracts with California Home Medical Equipment (CHME) for authorization management and servicing for the majority of Durable Medical Equipment (DME). To learn more about CHME’s authorization process, please click here. 

Under Health and Safety Code Section 1367.01(h)(1), the Alliance will decide routine pre-approvals (prior authorizations) within five (5) working days of when the Alliance gets the information reasonably needed to decide.  

For requests that a provider indicates, or the Alliance determines that following the standard time frame could seriously endanger your life or health or ability to attain, maintain, or regain maximum function, the Alliance will make an expedited (fast) pre-approval (prior authorization) decision. The Alliance will give you notice as quickly as your health condition requires and no later than 72 hours after getting the request for services.  

Pre-approval (prior authorization) requests are reviewed by clinical or medical staff, such as doctors, nurses and pharmacists. The Alliance does not pay the reviewers to deny coverage or services. If the Alliance does not approve the request, the Alliance will send you a Coverage Decision Letter. The letter will tell you how to file an appeal if you do not agree with the decision. The Alliance will contact you if the Alliance needs more information or more time to review your request.  

You never need pre-approval (prior authorization) for emergency care, even if it is out of the network and out of your service area withing the United States. This includes labor and delivery if you are pregnant. If you require emergency medical care outside the United States, the Alliance will review for these services afterward.  

You do not need pre-approval (prior authorization) for sensitive services, such as family planning, HIV/AIDS services, and outpatient abortions. For questions about pre-approval (prior authorization), call:  

Alameda Alliance Wellness Member Services Department
We are open Monday – Sunday (seven (7) days a week, including holidays), 8 am – 8 pm
Toll-Free: 1.888.88A.DSNP (1.888.882.3767)
If you cannot hear or speak well, use TTY or call 1.800.735.2929. 

Pre-Service Authorizations  

The Alliance Utilization Management (UM) Department must review and approve some types of care before they are provided. Your primary care provider (PCP) or specialist will work with the Alliance UM to get pre-service authorizations. The Alliance UM clinical review team of doctors determine whether the service is clinically appropriate, performed in the appropriate setting, and a part of your covered benefits.  

Your PCP or specialist will give the Alliance UM team the clinical information that is needed for all services that require a medical necessity review. Your PCP or specialist must select the “Type of Request” on the Prior Authorization (PA) Request Form and will indicate on the form how quickly the service needs to be completed by choosing urgent versus routine.  

Your PCP or specialist must also include all supporting clinical information with the initial request to help ensure a timely decision. If the clinical review information is not received with the PA Request Form, the Alliance UM team will contact your PCP or specialist to collect the needed information.  

Clinical information about a member may include:  

• Consultations 
• Diagnostic results  
• History of presenting problem  
• Member’s response to treatment  
• Photographs  
• Physical assessment  
• Previous and current treatment 

Your PCP or specialist should provide clinical information at least five (5) days prior to the planned service date to ensure timely notification of coverage approval. Your PCP or specialist is responsible for obtaining authorization. Your PCP or specialist must provide an authorization reference number on all referrals and claims.  

Post-Service/Retrospective Review  

The Alliance post-service retrospective review is the process that the Alliance Utilization Management (UM) team works with your PCP or specialist to determine medical necessity or coverage under the health plan benefit. Post-service/retrospective authorizations will only be considered if submitted within 90 days of the date of service.  

Prior Authorization Data 

We’re committed to transparency and helping you understand how we make care decisions. 

Since 2026 is our first year offering the Dual Eligible Special Needs Plan (D-SNP), we don’t have data to share about prior authorization requests. 

We will start sharing this information in 2027 after our first year of operation. 

As an Alameda Alliance Wellness member, you have access to behavioral health care services. The plan covers medically necessary behavioral health services.  These services include, but are not limited too: 

• Crisis Services 
• Mental health evaluation and treatment  
• Outpatient substance use  services 
• Outpatient services to monitor drug therapy   
• Psychiatric consultation  
• Psychological and neuropsychological  
• Transcranial Magnetic Stimulation (TMS)*’ 
• Electroconvulsive Therapy* 
• Intensive Outpatient Programs  
• Partial Hospitalization Programs  
• Residential Mental Health Services* 
• Inpatient psychiatric care 

For more information, please call Alameda Alliance Wellness at 1.888.88A.DSNP (1.888.882.3767). 

For additional resources, please click here. 

 *Prior authorization may be required and is the responsibility of your provider.    

The Alliance provides Community Health Worker (CHW) services to eligible members. 

Services currently available to Alameda Alliance Wellness members include: 

Health Education: Promote member health or address barriers to physical and mental health care by providing information or instruction on health topics. Health education content must be consistent with established or recognized health care standards and may include coaching and goal setting to improve a member’s health or ability to self-manage their health conditions.  

Health Navigation: Provide information, training, referrals, or support to assist members in accessing health care, understanding the health care delivery system, or engaging in their own care. This includes connecting members to community resources necessary to promote health; addressing barriers to care, including connecting to medical translation/interpretation or transportation services; or addressing health-related social needs. 

Under health navigation, CHWs can also:
Serve as a cultural liaison or assist a licensed health care provider to participate in the development of a plan of care, as part of a health care team.
Perform outreach and resource coordination to encourage and facilitate the use of appropriate preventive services; or
Help members enroll or maintain enrollment in government or other assistance programs that are related to improving their health if such navigation services are provided under a plan of care.

Screening and Assessment: Provide screening and assessment services that do not require a license and assist members with connecting to appropriate services to improve their health.

Individual Support or Advocacy: Assist members in preventing the onset or exacerbation of a health condition or preventing injury or violence. This includes peer support as well if not duplicative of other covered benefits. 

To learn more about the Community Health Worker benefits, please click here. 

Alliance members can receive Community Supports (CS) Services.  The Alliance currently offers the following Services: 

• Housing Transitions Navigation Services 
• Assists members with obtaining housing. 
• Housing Deposits 
• Assists members with identifying, coordinating, securing, or funding one-time services and modifications necessary to enable a member to establish a basic household (that do not constitute room and board). 
• Housing Tenancy and Sustaining Services 
• Assist members with providing tenancy and sustaining services, with a goal of maintaining safe and stable tenancy once housing is secured 
• Recuperative Care (Medical Respite)
• Short-term residential care for individuals who no longer require hospitalization, but still need to heal from an injury or illness (including behavioral health conditions) and whose condition would be exacerbated by an unstable environment. 
• Medically Tailored Meals/Medically-Supportive Food 
• Meals provided/delivered to the home that meet the unique dietary needs of those with chronic conditions, immediately following discharge from a hospital or nursing home. 
• Asthma Remediation 
• Physical modifications to a home environment that are necessary to ensure the health, welfare, and safety of the individual, or enable to individual to function in the home and without which acute asthma episodes could result in the need for emergency services and hospitalization. 
• (Caregiver) Respite Services 
• Assist members (and their caregivers) by providing relief support to caregivers, while continuing to serve members who live in the community and are compromised in their activities of daily living (ADLs). 
• Personal Care & Homemaker Services 
• Assist individuals who are approved (or in process) for In-Home Supportive Services 
• Environmental Accessibility Adaptations (Home Modifications) 
• Assist members who require physical adaptations to a home that are necessary to ensure health, welfare and safety of the individual, without which the member would require institutionalization. 
• Nursing Facility Transition/Diversion to Assisted Living Facilities, such as Residential Care Facilities for Elderly and Adult Residential Facilities 
• Assist individuals to live in the community and/or avoid institutionalization when possible. 
• Community Transition Services/Nursing Facility Transition to a Home
• Helps individuals to live in the community and avoid further institutionalization.

Community Supports Authorization forms can be found here:
www.alamedaalliance.org/providers/provider-forms/ 

For more information, to see if you are eligible, or would like to refer to any of the above programs please call:

Alameda Alliance Wellness Member Services Department
We are open Monday – Sunday (seven (7) days a week, including holidays), 8 am – 8 pm
Toll-Free: 1.888.88A.DSNP (1.888.882.3767)
If you cannot hear or speak well, use TTY or call 1.800.735.2929.

If you are no longer able to safely live in your home due to a health condition, we will provide you with continued care in long-term care facility, subacute facility, or intermediate care home. This service is a part of what is called the Long-Term Care (LTC) benefit. 

These places provide care 24 hours a day for people who cannot be at home but do not need to be in the hospital.  

The services provided under the Long-Term Care benefit may include: 

• Nursing care to help with bathing, eating, and getting dressed. 
• Your room and meals 
• Tests you may need (x-rays or lab work) 
• Therapy to help you be able to talk, move around, and take care of yourself. 
• Medicine that your doctor orders 

If you live in a long-term care facility, subacute facility, or intermediate care home now, you can remain there if you meet criteria. The Alliance will work with your doctor and the residence to coordinate your care. If your long-term care facility, subacute facility, or intermediate care home is outside of Alameda County, and you just joined our plan, you may continue to stay for another 12 months. At that time, we will work with your doctor to transfer your medical benefits to the county where you are located. 

Long-Term Care authorization forms can be found here: www.alamedaalliance.org/providers/provider-forms/ 

If you have any questions about long-term care and services, please call: 

Alameda Alliance Wellness Member Services Department
Monday –  Sunday (seven (7) days a week, including holidays), 8 am –   8pm
Toll-Free: 1.888.88ADSNP (888-882-3767)
If you cannot hear or speak well, use TTY or call: 1.800.735.2929.

The Health Risk Assessment (HRA) is a survey that seniors or persons with disabilities (SPDs) fill out each year.  

Why is it important? 
This tool helps our members share their health concerns with their doctor. It also helps us learn what other services they may need to stay healthy. 

What should I do with it?
Please complete the form and return it to us in the pre-paid envelope. After we receive your form, we will mail you and your doctor a care plan with community and health resources. The Alliance Case Management Program may also contact you to find out if you need more support. 

You can get prescription medications shipped to your home through our network mail-order delivery program which is called Walgreens Mail Service LLC. There is no extra cost for using the home delivery service.  

You will also have the choice to sign up for automated mail-order delivery through Walgreens Mail Service LLC. Typically, you should expect to get your drugs within 14 days from the time that the mail-order pharmacy gets the order. If you don’t get your drug(s) within this time, if you would like to cancel an automatic order, please contact Walgreens Mail Service LLC at 1. 800.345.1985.  

To sign-up for mail-order delivery, call Walgreens Mail Service at 1. 800.345.1985 or view Walgreens easy guide to see how to set up and use the home delivery service. 

To learn more about your plan benefits and covered services, please view your Alameda Alliance Wellness Member Handbook. 

The Alliance wants to help you get health care services and member materials in your preferred language and format.  

Our staff can help you:  

• Find a doctor who speaks your language. 
• Arrange for a qualified interpreter when you need one. In most cases, a telephonic interpreter will be used, but an in-person interpreter may also be used at no cost. Telephonic interpreter services are available 24 hours a day, 7 days a week.  
• Access to materials in alternative formats, such as braille and large print, or other aids and services for people with disabilities.  

To learn more, please click here.