Skip to main content

Reimbursement Forms

Prescription Reimbursement Form

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

One Care Member Reimbursement Form

Download:

Other Important Forms

Appointment of Representative Form

One Care Coverage Determination Request Form

Download:

One Care 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, Monday through Friday, and 8:00 am to 6:00 pm, Saturday and Sunday