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:

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

Navigate 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.

Annual Notice of Change

The Annual Notice of Change outlines changes to your benefits for the upcoming year:

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

Provider and Pharmacy Directory

The Provider and Pharmacy Directory lists the providers and pharmacies you can use. You can search for a provider or a pharmacy by clicking the links below:

You can also get a directory mailed to you

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.

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

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 CareSource before you can get them. We call this prior authorization.

Use this list to see which services need approval before you can get them.

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 Navigate Prior Authorization Request Form (Updated 5/19/2022).

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.

Navigate Notice of Formulary Changes (2/13/2024) Last updated on 2/13/2024 – Throughout the year, changes may occur to drugs on our formulary. Check this list to view the updates.

Coverage Determination Request Form online or Navigate hard copy (Updated 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 online or Navigate 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.

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 CareSource Dual Advantage plan by the Centers for Medicare & Medicaid Services (CMS). Plans are rated on a 5-point scale. Go to www.medicare.gov to learn more about Star Ratings.

Need Information in Another Language?

We can help! See our Navigate Multi-Language Interpreter Services for information to request plan documents in another language.

Non-Discrimination Notice

View CareSource’s Notice of Non-Discrimination.