Member Forms
At SummaCare, we want to make it easy for you to get the care and services you need as a member. In this section, you’ll find forms and information you can use to help you make the most of your SummaCare Secure plan.
Plan Change Form
To make a change in the Medicare Advantage plan you have with SummaCare, you will need to complete a Plan Selection Form. If you select another plan and we receive your completed Plan Selection form by December 7, 2011, your new benefit plan will begin on January 1, 2012.
You can return the completed form to us in one of the following ways:
Online:
Click HERE to complete a Plan Selection Form online.
Mail:
Click HERE to download a printable copy of the form. Complete the form and return it to:
SummaCare
ATTN: Eligibility
P.O. Box 3620
Akron, OH 44309-3620
Fax:
Click HERE to download a printable copy of the form. Complete the form and fax it to 330-996-8953.
Direct Debit/Credit Form
If you would like your monthly premium taken directly out of your savings/checking account or charged to a credit card, please print the Direct Debit/Credit Card Authorization Form. Send the completed form to:
SummaCare Secure
P.O. Box 3620
Akron, OH 44309-3620
You will receive a letter from us informing you when your request will become effective.
Medicare Part D Coverage Determination Request Form
If you would like to request that a drug be covered under your SummaCare Secure plan, please complete the Medicare Part D Coverage Determination Request Form . Send the completed form to:
MedImpact Healthcare Systems, Inc.
Scripps Corporate Plaza (TRE)
10680 Treena Street, Stop 5
San Diego, CA 92131
Fax: 858-790-7100
Request for Re-determination Medicare Prescription Drug Form
If you would like to request that a drug be re-determined under your SummaCare Secure plan, please complete the Re-determination Medicare Prescription Drug Denial Form. Sent the completed form to:
SummaCare Secure
P.O. Box 3620
Akron, OH 44309-3620
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 Secure
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. Send the completed form to:
SummaCare Secure
P.O. Box 3620
Akron, OH 44309-3620
Genetic Testing Prior Authorization Request Form
Prior Authorization is required for genetic testing. Please complete the Genetic Testing Prior Authorization Request Form and send it to:
SummaCare Secure
P.O. Box 3620
Akron, OH 44309-3620
Medicare Health Plan Rating
The Medicare Program rates how well Medicare Advantage performs in different categories (for example, detecting and preventing illness, rating from patients, patient safety and customer service). Click here for details.
Pharmacy Claim Reimbursement
Please complete the Pharmacy Claim Reimbursement Form and send it to:
MedImpact Healthcare Systems, Inc.
Scripps Corporate Plaza (TRE)
10680 Treena Street, Stop 5
San Diego, CA 92131
Fax: 858-790-7100
To Change Your Address:
Are you moving? To ensure you receive important plan information, please click here to complete and submit a Change of Address Form within 30 days of moving.
To Change Your Primary Care Physician (PCP):
Your relationship with your Primary Care Physician (PCP) is very important. SummaCare Secure members may change their PCP at any time by either clicking here to complete the online form or by calling Customer Service at 800-996-6250 (TTY 800-750-0750). A representative will be able to speak with you from 8 a.m. to 8 p.m. Monday through Friday.
Last Updated: 04/03/2012