Medicare Reference Documents

We know that no two states are the same when it comes to health care resources, community support and health care challenges. Below are some resources that you may need specifically for Ohio. These are documents that may be helpful at different times during your membership: 

Summary of Benefits

This booklet gives you a summary of costs and coverage in your plan. The complete list of services, limitations and exclusions are included in the Evidence of Coverage.

Evidence of Coverage

  • Out-of-Network Coverage Rules: Chapter 3
  • Exclusions & Limitations: Chapter 4, Section 3
  • Prior Authorization: Chapter 3 (medical) and Chapter 5 (prescription drug)
  • Appeals & Grievances: Chapter 9
  • Disenrollment: Chapter 10

Prescription Drug Mail Order Form

Use this order form to enroll and receive prescription drugs by mail.

Annual Notice of Change

If you are already a member of Buckeye Health Plan, this booklet will tell you about changes to your plan’s costs and benefits for the coming year.

Comprehensive Formulary

This is the complete list of prescription drugs covered by Buckeye Health Plan.

Other Resources

  • Appointing a Representative
    • Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.
  • Best Available Evidence (BAE)
    • This is a CMS policy that allows for changes to cost-sharing for low-income beneficiaries when there is evidence that information from a beneficiary is not up-to-date or accurate

Call Member Services at 1-866-389-7690 (TTY: 711) for help if you have questions. From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. On weekends and holidays, an automated system will handle your call.


Last Updated: 05/03/2017
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