Plan Documents

Review your CareSource Dual Advantage plan documents to make sure you get the most from your health insurance plan. You can also contact us with any questions you have about your plan coverage.

Evidence of Coverage (EOC)

The EOC is an important legal document that describes the relationship between CareSource and members of CareSource Dual Advantage™ (HMO D-SNP). It serves as your contract with CareSource and describes your member rights, responsibilities and obligations. It also tells you how the plan works, the covered services you are entitled to, any conditions and limits related to covered services, the health care services that are not covered by the plan, and the annual deductible, copayments, and coinsurance you must pay when you receive covered services.

Access the EOC below that corresponds to your plan and plan year:

2020

2021

Annual Notice of Change

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

2021

  • CareSource Dual Advantage (coming soon)

Provider and Pharmacy Directory

The Provider and Pharmacy Directory is a listing of the participating providers, including pharmacies, for MA-Dual Special Needs Plans. You may request a directory be mailed to you by clicking here.

You can also search for a provider or a pharmacy by clicking the links below:

  • Find a Doctor, an online search tool to find doctors, hospitals and other providers covered under your plan. Scroll down to select 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.

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.

2020

2021

Find Your County Below
Cuyahoga, Geauga, Holmes, Licking, Portage, Stark, SummitNavigateCareSource Dual Advantage
Adams, Brown, Champaign, Clark, Columbiana, Delaware, Fairfield, Fayette, Fulton, Greene, Hamilton, Hocking, Lake, Lucas, Madison, Mahoning, Medina, Mercer, Miami, Pickaway, Shelby, Trumbull, Union, WoodNavigateCareSource Dual Advantage
Auglaize, Butler, Clermont, Clinton, Coshocton, Crawford, Franklin, Hardin, Harrison, Henry, Highland, Logan, Lorain, Montgomery, Morrow, Ottawa, Perry, Preble, Putnam, Vinton, WarrenNavigateCareSource Dual Advantage

Forms

We want you to be able to easily locate all the forms you may need for your MA-Dual Special Needs Plans. Visit the Forms page to find any form when you need it.

Prior Authorization List

Some services require prior authorization from CareSource. This means your doctor or health care provider must get approval from CareSource before you can get the service.

The Prior Authorization List shows which services need a prior authorization 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 Prior Authorization Request Form.

Prescription Drug Benefit Documents

Below are links to documents covering your prescription drug benefits, including the latest drugs covered by the plan, a list of pharmacies in your area, and more.

Comprehensive Formulary – The MA-Dual Special Needs Plan formulary is a list of all drugs covered under your plan.

2020

2021

Notice of Formulary Changes – Throughout the year, changes may occur to drugs on our formulary. Check this list to view the updates.

Coverage Determination Request Form online or Navigatehard copy – If you believe you are entitled to payment or benefits on a certain drug, you can request a coverage determination by completing this form.

Coverage Redetermination Request Form online or Navigatehard 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 that you currently use 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 Multi-Language Interpreter Services for information to request plan documents in another language.

Non-Discrimination Notice

View CareSource’s notice of non-discrimination.