Skip to main content

Reimbursement Forms

Prescription Reimbursement Form

Follow the instructions on this form to submit a claim for reimbursement.

One Care Member Reimbursement Form


Other Important Forms

Appointment of Representative Form

One Care Request for Redetermination of Medicare Prescription Drug Denial


We’re here to support you

866-610-2273 (TTY 711)
8:00 am to 8:00 pm, 7 days a week