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Reimbursement Forms

CCA Medicare Plans (MA) – Prescription Reimbursement Form

Other Important Forms

CCA Massachusetts – Prescription Drug Coverage Determination Request 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.

Vaccine Coverage Determination Request Form

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