In this section, you'll find forms and contact information to make the most of your SummaCare Medicare Advantage plan.
If you would like to appoint a representative who can act on your behalf, please download and complete an Appointment of Representative Form. Send the completed form to:
SummaCare
P.O. Box 3620
Akron, OH 44309-3620
Some healthcare services require prior authorization (approval by SummaCare in advance). To request prior authorization, please complete the Prior Authorization Request Form for Services or or the Prior Authorization Request Form for Drugs Covered Under the Medical Benefit. Send the completed form to:
SummaCare
P.O. Box 3620
Akron, OH 44309-3620
If you paid out-of-pocket for a service or supply and would like to request reimbursement, please complete the Medicare Claim Form and send it, along with an itemized bill from your doctor or supplier to:
SummaCare
1200 E. Market Street, Suite 400
Akron, OH 44305
If you paid out-of-pocket for your prescription drugs and would like to request reimbursement, please complete the Medicare Part D Prescription Drug Claim Formand send it, along with the appropriate prescription receipts/labels to:
MedImpact Healthcare Systems, Inc.
PO Box 509108
San Diego, CA 92150-9108
Fax: 858.549.1569
E-Mail: claims@Medimpact.com
If you would like to request that a drug be covered under your SummaCare plan, please complete the Medicare Part D Coverage Determination Request Form - Updated October 1, 2021.
Once you print and complete the form, please mail or fax it to:
MedImpact Healthcare Systems, Inc.
10181 Scripps Gateway Court
San Diego, CA 92131
Fax: 858.790.7100
Coverage determinations can also be made by phone:
Phone: 877.391.1109
You’ll receive an annual allowance to use toward the purchase of standard eyeglasses and frames or contact lenses. You have the freedom to visit any vision provider you choose. Simply submit a vision claim form and your receipt to us and you’ll be reimbursed up to your annual allowance.
SummaCare Claims
PO Box 3620
Akron, OH 44309-3620
The Over-the-Counter (OTC) benefit catalog lists items covered and includes an order form and other instructions on how to obtain items.
If you would like to add supplemental dental to your 2023 SummaCare Medicare Advantage Plan for an additional $35 per month, please complete the <2023 Delta Dental Enrollment Form> and return to the address on the form.