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Member Forms

In this section, you'll find forms and contact information to make the most of your SummaCare Medicare Advantage plan.

Appointment of Representative Form

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

Prior Authorization Request Form

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

Medicare Claim Form

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

Pharmacy Claim Reimbursement Form

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

Part D Coverage Determination Request Form

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

Prescription Eyewear Reimbursement Form

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

Over-the-Counter Catalog & Order Form

The Over-the-Counter (OTC) benefit catalog lists items covered and includes an order form and other instructions on how to obtain items.

Optional Supplemental Dental

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. 

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