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Reimbursement Forms

CCA Senior Care Options – Prescription 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.

CCA Massachusetts – Prescription Drug Coverage Determination Request Form

CCA Senior Care Options – Request for Redetermination of Medicare Prescription Drug Denial

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.

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