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 Medicare Plans (MA) – Prescription Reimbursement Form
Vision Reimbursement Form
Other Important Forms
Appointment of Representative Form
CCA Massachusetts – Prescription Drug Coverage Determination Request Form
Costco Mail Order Pharmacy Form
Financial Hardship Policy
Financial Assistance Application
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.