Member Forms
Find forms for coverage exceptions, reimbursements, and other requests.
Reimbursement Forms
CCA Member Reimbursement Form
2027 CCA Senior Care Options – Prescription Reimbursement Form
Coming Soon
2026 CCA Senior Care Options – Prescription Reimbursement Form
2027 CCA Senior Care Options – Prescription Drug Coverage Determination Request Form
Coming Soon
2026 CCA Senior Care Options – Prescription Drug Coverage Determination Request Form
Vision Reimbursement Form
Other Important Forms
Appointment of Representative Form
2027 CCA Senior Care Options – Request for Reconsideration of Medicare Prescription Drug Denial (2027)
Coming Soon
2026 CCA Senior Care Options – Request for Reconsideration of Medicare Prescription Drug Denial
CCA Senior Care Options – Request for Redetermination of Medicare Prescription Drug Denial (2027)
Coming Soon
2026 CCA Senior Care Options – Request for Redetermination of Medicare Prescription Drug Denial
CVS Caremark Mail Order Pharmacy Form
CCA Senior Care Options – Member Claims Form
Part D Late Enrollment Penalty (LEP) Reconsideration Request Form
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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