2026 Plan Documents

Member Handbook/Evidence of Coverage (EOC)
The Member Handbook also known as the Evidence of Coverage (EOC) describes in detail everything the plan covers, including medical services, prescription drugs, and member rights. It explains how to get the coverage you need.

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Summary of Benefits (SOB)
The Summary of Benefits (SOB) is a simplified document that outlines benefits and coverage. 
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Annual Notice of Change (ANOC)
The Annual Notice of Change (ANOC) is a summary of any changes in the costs and coverage between plan benefit years 2026 and 2027. These changes take effect on January 1, 2027.

Formulary (list of drugs)
The Formulary is a list of drugs covered by the plan. 
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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.
To view a copy of the Alliance Provider Directory for Alameda Alliance Wellness members, please click here.
You can also search for a provider in our online Alliance Provider Directory.

Enrollment Form
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Pre-enrollment Checklist
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Stay informed about notices and announcements that may impact your coverage, benefits, or plan rules.

Supplemental Benefit Highlight Flyer
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Over-the-Counter (OTC) Benefits Catalog
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Wellness Programs & Materials Request Form 
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Alameda Alliance Wellness partners with Liberty Dental to provide some of your dental benefits. Dental services may include, but are not limited to, an oral exam, restorative services (crowns), removable prosthodontic services (rebases), and fixed prosthodontic services (pontic & retainer crowns).

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
People with hearing and speaking impairments (CRS/TTY): 1.877.855.8039.
Liberty Dental representatives are available to assist you Pacific Time (PT):
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 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, or find a provider, please contact:

Medi-Cal Dental
Toll-Free: 1.800.322.6384
People with hearing and speaking impairments (CRS/TTY): 1.800.735.2922
Medi-Cal Dental representatives are available to assist you Monday through Friday, 8 am to 5 pm.
smilecalifornia.org

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

Frequently Asked Questions

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

• One (1) routine hearing exam every year
• Up to $775 (per ear) for up to two prescription hearing aids per year.
• One (1) hearing aid fitting/evaluation 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) 8 am – 8 pm, local time.
www.alliancewellness.nationsbenefits.com/hearing

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

Frequently Asked Questions

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Alameda Alliance Wellness partners with NationsBenefits to provide a quarterly $110 allowance to purchase over-the-counter (OTC) items. This benefit can be used to buy non-prescription products such as cough and cold medicine, vitamins, pain relievers, bandages, and more.

A prepaid debit card, along with activation instructions, will be mailed to you. You can use your debit card to purchase eligible OTC products from the NationsBenefits catalog by shopping in-store, online, or by phone. Unused amounts do not carry forward to the next quarter.

To learn more about your plan benefits and covered services, order an OTC product catalog, find participating retail locations, or for other questions, please contact:

NationsBenefits
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) 8 am – 8 pm, local time.
www.alliancewellness.nationsbenefits.com

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 benefits and covered services, please view your Alameda Alliance Wellness Member Handbook.  

Frequently Asked Questions

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Alameda Alliance Wellness partners with Vison Service Plan (VSP) to provide your routine eyecare services. We pay for the following services:

• One (1) routine eye exam every year and
• Up to $150 for one (1) pair of prescription eyeglasses (frames) or prescription contact lenses every two (2) years. Standard lenses (single vision, lined bifocals, or lined trifocals) are covered in full every two (2) years.

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

VSP
Toll-Free: 1.855.492.9028
If you cannot hear or speak well, use TTY (711).
VSP representatives are available to assist you seven (7) days a week, 8 am – 8 pm.

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

Frequently Asked Questions

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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. 

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 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 see the “Plan Documents” section above on this page to view your Alameda Alliance Wellness Member Handbook.  

As an Alameda Alliance Wellness member, you have the option for certain telehealth services, including physician and practitioner services to treat non-emergency conditions under General Medicine, Dermatology and Mental Health.

You have the option of getting these services by phone or video. If you choose to get one of these services by telehealth, you must use a network provider who offers the service by telehealth.

Teladoc provides physician consultations by phone or video from the comfort of your own home 24 hours a day, 7 days a week. Talk to a doctor by calling Teladoc at 1.800.TELADOC (1.800.835.2362) or by scheduling a video chat on the Teladoc app to treat non-emergency medical issues.

To learn more about the Alameda Alliance Wellness Teladoc benefit, please click here.

Alameda Alliance Wellness covers emergency services outside the United States with a $25,000 annual maximum benefit for worldwide emergency care, worldwide urgently needed care, and worldwide emergency ambulance services combined. You may have to pay the provider at the time of service and submit for reimbursement. You will be reimbursed up to the annual maximum benefit amount.

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

Pre-approval (prior authorization)  

For the Prior Authorization requests, your PCP or specialist must also include all supporting clinical information with the initial request to help ensure a timely decision. 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, 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 seven (7) calendar 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 within 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 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 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. 

You are also able to call the Alliance and make a request to have a service that requires a prior authorization. The Alliance team members will work with your PCP or specialist to obtain the necessary information to complete a medical necessity evaluation within seven (7) calendar days for routine requests or 72 hours for urgent requests.

For the Prior Authorization requests, your 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.

We share this information every year to explain how our prior authorization (PA) process works. These numbers show how many PA requests we approve or deny, how long decisions take, and how many appeals are approved if you ask us to look at a decision again. They also show a list of all medical items and services (excluding drugs) that require prior authorization.

2025 Prior Authorization Data

Policies & Procedures

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 to: 

• 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 in creating a plan of care or treatment plan as part of a health care team.
• A CHW may also draft a plan of care or treatment plan that identifies interventions for CHW services, which is then reviewed and approved by a licensed provider; or
• Perform outreach and resource coordination to encourage and facilitate the use of appropriate preventive services; or
• Help a member identify and/or select a primary care provider that meets their individual needs; or
• Help a member initially enroll or maintain enrollment in Medi-Cal, including support with obtaining necessary documentation, as well as other government or assistance programs, such as CalWORKs or CalFresh, that are related to improving their health.

Screening and Assessment: Provide screening and assessment services that does 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.

Violence Prevention Services: CHWs may also provide violence prevention services, which include all the CHW services described above (i.e., health education, health navigation, screening and assessment, and individual support and advocacy), as these services apply specifically to violence prevention.

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 the to individual to function in the home and without which acute asthma episodes could result in the need for emergency services and hospitalization. 
• (unpaid Caregiver) Respite Services 
  • Assist members who are in an active assessment or reassessment period with In-Home Supportive Services and require additional support to avoid institutionalization. 
• Assisted Living Facility (ALF) Transitions
  • 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 or Home Transition Services
  • 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, 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
Seven (7) days a week, including holidays), 8 am – 8pm
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.

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.