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
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.
This is the complete list of prescription drugs covered by Buckeye Health Plan.
- Provider & Pharmacy Directory Information
- This is an introduction to the provider and pharmacy directory, including an explanation of the provider symbols found in the directory.
- Personal Health Information (PHI) Authorization Form
- Use this form when you want to allow Buckeye Health Plan to share your health information with a person or group.
- Personal Health Information (PHI) Revocation Form
- Use this form when you want to cancel or revoke your previous permission to share health information with a person or group.
- 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.
- Multi-Language Interpreter Services - 2017
- We have free interpreters to answer questions in multiple languages: 1-866-389-7690.
- File a complaint directly with CMS
- Submit feedback about your Medicare plan directly to Medicare.gov.
- Stop Medicare Fraud, Waste and Abuse
- Learn how to identify, prevent and report Medicare fraud, waste or abuse.
- Office for Civil Rights
- The OCR protects your health information privacy rights and right to nondiscrimination.
- The Office of the Medicare Ombudsman (OMO)
- The Medicare Beneficiary Ombudsman helps you with Medicare-related complaints, grievances, and information requests.
- 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