Exceptions and Appeals

If you want to voice a disagreement with a coverage decision through SummaCare or would like to request an exception to coverage of a prescription drug, please click on one of the links below and dowload the appropriate form. Once you complete the form, please return it to:

SummaCare Customer Service
P.O. Box 3620
Akron, OH 44309-3620

If you would like to appoint a representative who can act on your behalf, please download and complete an Appointment of Representative Form [PDF].

If you would like to request that a drug be covered under the plan, please download and complete the Medicare Part D Coverage Determination Request Form [PDF].

Or click a link below to download the appropriate document now:

Pharmacy Appeals and Exceptions [PDF]
Medical Appeals [PDF]

For complete information, please refer to your Evidence of Coverage document.