Member Forms
On this page you’ll find important forms you can use to request coverage exceptions, reimbursements, and more.
Reimbursement Forms
CCA Member Reimbursement Form
CCA Senior Care Options – Prescription Reimbursement Form
CCA Senior Care Options – Prescription Drug Coverage Determination Request Form (2025)
Please be advised, this form cannot be submitted for 2025 PA requests until December 1, 2024.
Vision Reimbursement Form
Other Important Forms
Member Chronic Condition Coverage Request Form (MA)
Our members with certain health conditions or adverse health outcomes may be eligible for additional benefits under the Special Supplemental Benefits for the Chronically Ill (SSBCI). This form should be used by members to request that CCA determine eligibility for SSBCI benefits.
Appointment of Representative Form
CCA Senior Care Options – Prescription Drug Coverage Determination Request Form
CCA Senior Care Options (HMO D-SNP) – Request for Reconsideration of Medicare Prescription Drug Denial (2025)
CCA Senior Care Options – Request for Redetermination of Medicare Prescription Drug Denial
Costco Mail Order Pharmacy Form (2024)
CVS Caremark Mail Order Pharmacy Form (2025)
Vaccine Coverage Determination Request Form
Part D Late Enrollment Penalty (LEP) Reconsideration Request Form
Release of Information (ROI) Form
This form is used to release your health information from CCA to a person or organization. It can also be used to request your health information from a person or organization, such as a healthcare provider or hospital, to be shared with CCA.