Skip to main content

Reimbursement Forms

Prescription Reimbursement Form

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

Healthy Savings OTC Reimbursement Form

Download:

Senior Care Options General Reimbursement Request Form

Download:

Senior Care Options Wellness Allowance Reimbursement Request Form

Download:

Other Important Forms

Appointment of Representative Form

Coverage Determination Request Form

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

Download:

We’re here to support you

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