Member Forms
Find forms for coverage exceptions, reimbursements, and other requests.
Reimbursement Forms
CCA Member Reimbursement Form
CCA One Care – Prescription Reimbursement Form
CCA One Care – Prescription Drug Coverage Determination Request Form
Other Important Forms
Appointment of Representative Form
CCA One Care – Request for Reconsideration of Medicare Prescription Drug Denial
CCA One Care – Request for Redetermination of Medicare Prescription Drug Denial
CVS Caremark Mail Order Pharmacy Form
CCA One Care – Member Claims Form
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Release of Information (ROI) Form
Use this form to share your health information from CCA with a person or organization. You can also use it to ask a doctor, hospital, or other organization to share your health information with CCA.
State Fair Hearing Request Form – Appeals and Grievances
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866-537-5816
(TTY 711)
Monday through Friday, 8 am to 8 pm Eastern Time, and from October 1 to March 31, the same hours, 7 days a week.
