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Plan Documents

Medicare Plan Documents

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.

Annual Notice of Change Documents

Evidence of Coverage

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

Summary of Benefits

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 May 9, 2023
2023 Summary of Benefits - Jade - Updated May 9, 2023
2023 Summary of Benefits - Sapphire and Emerald - Updated October 1, 2022

Delta Dental Certificate of Insurance (COI) Documents

If you have purchased optional supplemental dental coverage for an additional premium of $35 per month for 2023, the Delta Dental Certificate of Insurance provides a detailed explanation of this supplemental coverage. It includes information about your dental provider network, coverage amounts and other important topics.

2023
2023 Delta Dental Certificate of Insurance (COI) Topaz, Jade Supplemental 0008 - Updated April 11, 2023
2023 Delta Dental Certificate of Insurance (COI) Ruby Supplemental 0009 - Updated April 11, 2023
2023 Delta Dental Certificate of Insurance (COI) Garnet 1006 - Updated April 11, 2023
2023 Delta Dental Certificate of Insurance (COI) Amber, Sapphire, Emerald 1007 - Updated April 11, 2023
2023 Delta Dental Certificate of Insurance (COI) Topaz, Jade 1008 - Updated April 11, 2023
2023 Delta Dental Certificate of Insurance (COI) Ruby 1009 - Updated April 11, 2023
2023 Delta Dental Certificate of Insurance (COI) Garnet Supplemental 0006 - Updated April 11, 2023
2023 Delta Dental Certificate of Insurance (COI) Amber, Sapphire, Emerald Supplemental 0007 - Updated April 11, 2023

Request Member Materials

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.

Questions?  We are here to help.

By Phone

Member Services:
330.996.8885

toll free
800.996.6250
(TTY 800.750.0750)

Hours

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.

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