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Administrative Forms

Prior Authorization Form MI

Authorization to Release PHI MI

Appeals and Grievances

Prior Authorization Request Form (OptumRx) MI

Redetermination Request Form MI

Coverage Determination Form MI

File a Complaint MI

When you click the link below, you will leave the CCA Health Michigan, Inc. website and land on

Appointment of Representative Form


CCA Health Michigan works in partnership with its Pharmacy Benefit Manager, OptumRx, to provide Medicare Part D prescription reimbursements.

To submit a claim for reimbursement of medications, please fill out a prescription reimbursement form. Forms can be mailed to OptumRX using the contact information provided on the form.

The number of days after the fill date a manual claim can be submitted is 1,095 days.

OptumRx Medicare Part D Claim Form (MI) (2024)

Other Important Forms

Member Chronic Condition Coverage Request Form (MI)

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.

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855-959-5855 (TTY 711)
April 1 to September 30, 8 am – 8 pm, Monday – Friday