About Your Health Plan

Dual Eligible Special Needs Plans (D-SNPs) are a type of Medicare Advantage plan for people who qualify for both Medicare and Medi-Cal. Medicare is mainly for people 65 and older, while Medi-Cal helps people with low income. Some states also cover other people, based on their state’s rules. D-SNPs coordinate your health care and often include extra benefits that regular Medicare Advantage plans don’t have.

The TotalCare plan is a special type of D-SNP called an Exclusively Aligned Enrollment (EAE) D-SNP. “Exclusively aligned enrollment” means that you get both your Medicare and Medi-Cal benefits from the same organization—in this case, the Alliance.

As a TotalCare member, you can access your Medi-Cal and Medicare benefits from one organization, the Alliance. Some advantages of this type of plan include:

• One plan that manages all your care.
• Extra benefits beyond standard Medicare and Medicaid coverage.
• A single member ID card and member handbook with details about both programs.
• Care coordination and case management through a care coordinator who is your main point of contact.
• Clearer communication for you and your providers.
• Access to specialists who accept both Medicare and Medicaid.

TotalCare coordinates your Medi-Cal and Medicare benefits through the TotalCare plan. You can learn more about all the benefits this plan has – including “extra” benefits – by visiting the Access Benefits page.

All TotalCare plan materials are available on the Member Materials page. The documents listed on this page can be easily viewed or downloaded as a PDF.

If you need medications for a sickness or condition, your doctor will give you a prescription. You will have no or low copays for prescriptions covered under the drug benefit.

To see if TotalCare will cover your prescription, you can do one of the following:

• Check our searchable online formulary. Look for the drug by its generic or brand name.
• Download a copy of the formulary.
• Have a copy of the formulary mailed to you. Call Member Services to get the formulary mailed to you.

TotalCare covers brand and generic prescription drugs that are filled by network pharmacies. To find a network pharmacy near you, search the online Pharmacy Directory. If you have questions about your prescription, you can ask the pharmacist.

You will have no or low copays for prescriptions covered under the drug benefit. You should only receive services from in-network providers. If you receive care from an out-of-network provider, the service may not be covered unless it’s an emergency or has been approved by the Alliance. If the provider is out of network, they may not understand the TotalCare plan or the plan’s billing rules. If you receive a bill for Medicare-covered services, please call Member Services.

TotalCare coordinates your Medi-Cal and Medicare benefits through the TotalCare plan. We also provide extra benefits, including:

• Flex Card. You will get a $100 allowance per quarter for over the counter (OTC) products.
• Vision care. This includes one no-cost annual exam and $350 for glasses or contacts every 2 years.
• The Silver&Fit® Healthy Aging and Exercise program offers flexible fitness options that support physical activity, well-being, community building, and healthy aging.