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
Download:
CCA Senior Care Options – Prescription Reimbursement Form
Download:
Vision Reimbursement Form
Download:
Other Important Forms
Appointment of Representative Form
Download:
CCA Massachusetts – Prescription Drug Coverage Determination Request Form
Download:
CCA Senior Care Options – Request for Redetermination of Medicare Prescription Drug Denial
Download:
Costco Mail Order Pharmacy Form
Download:
Vaccine Coverage Determination Request Form
Download:
Part D Late Enrollment Penalty (LEP) Reconsideration Request Form
Download: