To view and print an EOC or other plan documents, please select from the options below. If you would like to request a hard copy of a document mailed to you, please submit the form located below.
SummaCare members receive the Annual Notice of Change (ANOC) documents in September of every year.
2023
2023 ANOC Amber - Updated October 1, 2022
2023 ANOC Topaz - Updated October 1, 2022
2023 ANOC Garnet - Updated October 1, 2022
2023 ANOC Ruby - Updated October 1, 2022
2023 ANOC Sapphire - Updated October 1, 2022
2023 ANOC Emerald - Updated October 1, 2022
The Evidence of Coverage (EOC) document is a detailed explanation of the health and prescription drug benefits and services available to you. It includes information on how to use your coverage, details about your copays, a description of your member rights and responsibilities and a glossary of terms.
Please note: Information about SummaCare's grievance, coverage determination (including exceptions) and appeals processes can be found in Chapter 9 of each of the documents below.
2023
2023 EOC SummaCare Amber - Updated October 1, 2022
2023 EOC SummaCare Topaz - Updated October 1, 2022
2023 EOC SummaCare Jade 1 - Updated October 1, 2022
2023 EOC SummaCare Jade 2 - Updated October 1, 2022
2023 EOC SummaCare Garnet - Updated October 1, 2022
2023 EOC SummaCare Ruby - Updated October 1, 2022
2023 EOC SummaCare Sapphire - Updated October 1, 2022
2023 EOC SummaCare Emerald - Updated October 1, 2022
2022
2022 EOC SummaCare Amber - Updated October 1, 2021
2022 EOC SummaCare Topaz - Updated October 1, 2021
2022 EOC SummaCare Garnet - Updated October 1, 2021
2022 EOC SummaCare Ruby - Updated October 1, 2021
2022 EOC SummaCare Sapphire - Updated October 1, 2021
2022 EOC SummaCare Emerald - Updated October 1, 2021
The Summary of Benefits (SOB) document provides a summary of your medical and prescription drug benefits, including copay information. The SOB lists the primary features of your SummaCare plan. Please note, however, that it does not list every service that we cover or list every limitation or exclusion. For a complete list of benefits, refer to your EOC document.
2023
2023 Summary of Benefits - Amber - Updated October 1, 2022
2023 Summary of Benefits - Topaz, Garnet and Ruby - Updated October 1, 2022
2023 Summary of Benefits - Jade - Updated October 1, 2022
2023 Summary of Benefits - Sapphire and Emerald - Updated October 1, 2022
2022
2022 Summary of Benefits - Amber - Updated October 1, 2021
2022 Summary of Benefits NE Region - Topaz, Garnet and Ruby - Updated October 1, 2021
2022 Summary of Benefits NE Region - Sapphire and Emerald - Updated October 1, 2021
2022 Summary of Benefits NW Region - Ruby and Sapphire - Updated October 1, 2021
If you have purchased optional supplemental dental coverage for an additional premium of $35 per month for 2023 or $28 per month for 2022, the Delta Dental Certificate of Insurance providers a detailed explanation of this supplemental coverage. It includes information about your dental provider network, coverage amounts and other important topics.
Check back for the 2023 Delta Dental Certificate of Insurance (COI) documents.
2022
2022 Delta Dental Certificate of Insurance (COI) - All plans except Garnet - Updated October 1, 2021
2022 Delta Dental Certificate of Insurance (COI) - Garnet plan - Updated October 1, 2021
To request a hard copy of an evidence of coverage document, provider directory or formulary be mailed to you, please call SummaCare Member Services at 330.996.8885 or 800.996.6250 (TTY 800.750.0750) or complete the online request form.
From October 1 - March 31
8:00am to 8:00pm
seven days a week
From April 1 - September 30
8:00am to 8:00pm
Monday - Friday
Outside these hours, you may leave us a message and a representative will return your call the next business day.