Plan Documents
Review these important documents for your plan. Questions? Call us!
Evidence of Coverage (EOC)
The EOC gives the details for your plan including what the plan covers, how much you pay and more. See the EOC for your plan and plan year:
OHIO
Find Your County Below | |
---|---|
Ashland, Carroll, Cuyahoga, Geauga, Hancock, Holmes, Lawrence, Licking, Portage, Stark, Summit, Tuscarawas, Wayne |
|
Adams, Ashtabula, Athens, Belmont, Brown, Champaign, Clark, Columbiana, Darke, Defiance, Delaware, Fairfield, Fayette, Fulton, Gallia, Greene, Hamilton, Hocking, Huron, Lake, Lucas, Madison, Mahoning, Medina, Mercer, Miami, Monroe, Morgan, Muskingum, Pickaway, Richland, Sandusky, Seneca, Shelby, Trumbull, Union, Van Wert, Williams, Wood, Wyandot |
|
Allen, Auglaize, Butler, Clermont, Clinton, Coshocton, Crawford, Erie, Franklin, Guernsey, Hardin, Harrison, Henry, Highland, Jackson, Jefferson, Logan, Lorain, Marion, Meigs, Montgomery, Morrow, Noble, Ottawa, Paulding, Perry, Pike, Preble, Putnam, Ross, Scioto, Vinton, Warren, Washington |
|
Benefits at a Glance
Benefits at a Glance: Use this guide to see your benefits and services! You can learn more about these benefits and services in your Evidence of Coverage.
GEORGIA
Find Your County Below | |
---|---|
Bibb, Clarke, Clayton, Cobb, Coweta, Dawson, Douglas, Fulton, Gwinnett, Habersham, Henry, Lumpkin, Rockdale, Stephens |
|
Baldwin, Barrow, Cherokee, Fayette, Forsyth, Greene, Houston, Jackson, Madison, Monroe, Morgan, Newton, Oconee, Oglethorpe, Paulding, Peach, Putnam, Spalding, Walton |
|
Annual Notice of Change
The Annual Notice of Change outlines changes to your benefits for the upcoming year:
OHIO
Find Your County Below | |
---|---|
Ashland, Carroll, Cuyahoga, Geauga, Hancock, Holmes, Lawrence, Licking, Portage, Stark, Summit, Tuscarawas, Wayne |
|
Adams, Ashtabula, Athens, Belmont, Brown, Champaign, Clark, Columbiana, Darke, Defiance, Delaware, Fairfield, Fayette, Fulton, Gallia, Greene, Hamilton, Hocking, Huron, Lake, Lucas, Madison, Mahoning, Medina, Mercer, Miami, Monroe, Morgan, Muskingum, Pickaway, Richland, Sandusky, Seneca, Shelby, Trumbull, Union, Van Wert, Williams, Wood, Wyandot |
|
Allen, Auglaize, Butler, Clermont, Clinton, Coshocton, Crawford, Erie, Franklin, Guernsey, Hardin, Harrison, Henry, Highland, Jackson, Jefferson, Logan, Lorain, Marion, Meigs, Montgomery, Morrow, Noble, Ottawa, Paulding, Perry, Pike, Preble, Putnam, Ross, Scioto, Vinton, Warren, Washington |
|
GEORGIA
Find Your County Below | |
---|---|
Bibb, Clarke, Clayton, Cobb, Coweta, Dawson, Douglas, Fulton, Gwinnett, Habersham, Henry, Lumpkin, Rockdale, Stephens |
|
Baldwin, Barrow, Cherokee, Fayette, Forsyth, Greene, Houston, Jackson, Madison, Monroe, Morgan, Newton, Oconee, Oglethorpe, Paulding, Peach, Putnam, Spalding, Walton |
|
Provider and Pharmacy Directory
- , an online search tool to find doctors, hospitals and other providers covered under your plan. Click on Get Started and fill out location information. Under the Choose Ë¿¹Ï¶ÌÊÓƵ page, scroll to your state and filter the results under Medicare by selecting Dual Special Needs from the list
- Find a Pharmacy, an online search tool to find pharmacies in your area.
You can also .
Summary of Benefits
The Summary of Benefits outlines the key features of the plan, such as the covered benefits, cost-sharing provisions, and coverage limitations and exceptions.
OHIO
Find Your County Below | |
---|---|
Ashland, Carroll, Cuyahoga, Geauga, Hancock, Holmes, Lawrence, Licking, Portage, Stark, Summit, Tuscarawas, Wayne |
|
Adams, Ashtabula, Athens, Belmont, Brown, Champaign, Clark, Columbiana, Darke, Defiance, Delaware, Fairfield, Fayette, Fulton, Gallia, Greene, Hamilton, Hocking, Huron, Lake, Lucas, Madison, Mahoning, Medina, Mercer, Miami, Monroe, Morgan, Muskingum, Pickaway, Richland, Sandusky, Seneca, Shelby, Trumbull, Union, Van Wert, Williams, Wood, Wyandot |
|
Allen, Auglaize, Butler, Clermont, Clinton, Coshocton, Crawford, Erie, Franklin, Guernsey, Hardin, Harrison, Henry, Highland, Jackson, Jefferson, Logan, Lorain, Marion, Meigs, Montgomery, Morrow, Noble, Ottawa, Paulding, Perry, Pike, Preble, Putnam, Ross, Scioto, Vinton, Warren, Washington |
|
GEORGIA
Find Your County Below | |
---|---|
Bibb, Clarke, Clayton, Cobb, Coweta, Dawson, Douglas, Fulton, Gwinnett, Habersham, Henry, Lumpkin, Rockdale, Stephens |
|
Baldwin, Barrow, Cherokee, Fayette, Forsyth, Greene, Houston, Jackson, Madison, Monroe, Morgan, Newton, Oconee, Oglethorpe, Paulding, Peach, Putnam, Spalding, Walton |
|
Forms
Visit the Forms page to find forms when you need them.
Prior Authorization List
Some services need your doctor or provider to get approval from Ë¿¹Ï¶ÌÊÓƵ before you can get them. We call this prior authorization.
Use this list to see which services need approval before you can get them.
-
2024 Prior Authorization List
Last updated on 10/01/2023
Usually, your primary care provider (PCP) will ask for prior authorization from us and then schedule these services for you. If you are seeing a specialist, he or she will get approval from your PCP. Then your services will be scheduled. If you have questions about the prior authorization process or status, please call Member Services.
Your provider can submit a request for a prior authorization using the Prior Authorization Request Form Last updated on 05/19/2022.
Prescription Drug Benefit Documents
Below are links to documents covering your prescription drug benefits.
Comprehensive Formulary – A list of all drugs covered under your plan.
Notice of Formulary Changes Last updated on 09/01/2024 – Throughout the year, changes may occur to drugs on our formulary. Check this list to view the updates.
Coverage Determination Request Form or hard copy Last updated on 3/01/2021 – If you believe you are entitled to payment or coverage on a certain drug, you can request a coverage determination by completing this form.
Coverage Redetermination Request Form or hard copy – If you are unsatisfied with the outcome of a coverage determination request, you can file an appeal using the redetermination form.
Prior Authorization Criteria – For certain drugs, your doctor will need to contact us before you can fill your prescription.
Step Therapy Criteria – For certain drugs, we require you to first try another drug to treat your medical condition before we will cover the drug your physician initially prescribed.
-
2024 Step Therapy Criteria
Last updated on 09/01/2024
Drug Transition Policy – Learn about our policy for potentially covering a drug you currently take that is not listed in our formulary.
Star Ratings
Star Ratings are given to the Ë¿¹Ï¶ÌÊÓƵ Dual Advantage plan by the Centers for Medicare & Medicaid Services (CMS). Ë¿¹Ï¶ÌÊÓƵ are rated on a 5-point scale. Go to to learn more about Star Ratings.
-
2024 Georgia Star Ratings
Last updated on 10/24/2023 - 2024 Ohio Star Ratings:
-
2024 Georgia Star Ratings
Need Information in Another Language?
We can help! See our Multi-Language Interpreter Services for information to request plan documents in another language.