Fillable Prescription Drugs Payment Request Form (CalOptima)

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Prescription Drugs Payment Request Form (CalOptima)

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The Prescription Drugs Payment Request Form (CalOptima) form is 3 pages long and contains:

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  • 6 check-boxes
  • 46 other fields

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H8016_PD16_34 Accepted (1/15/16)
Prescription Drugs Payment Request Form
Member Information
Name (First, Middle, Last):
Member ID (CIN):
Phone Number:
Address where you live:
Address:
City, State, ZIP code:
City:
State: ZIP code:
Address where want to receive
your check:
(if different from where you live)
Address:
City, State, ZIP code:
City:
State: ZIP code:
Payment Request #1: Prescription Drug Information
Name of drug:
Strength of drug: (if known)
Quantity of drug: (if known)
Date prescription was filled:
Amount paid:
$
Pharmacy Name:
Pharmacy Phone Number:
Why did you pay for this
drug?
Did you attach the receipt?
Yes No
Payment Request #2: Prescription Drug Information
Name of drug:
Strength of drug: (if known)
Quantity of drug: (if known)
Date prescription was filled:
Amount paid:
$
Pharmacy Name:
Pharmacy Phone Number:
Why did you pay for this
drug?
Did you attach the receipt?
Yes No
Payment Request #3: Prescription Drug Information
Name of drug:
Strength of drug: (if known)
Quantity of drug: (if known)
Date prescription was filled:
Amount paid:
$
Pharmacy Name:
Pharmacy Phone Number:
Why did you pay for this
drug?
Did you attach the receipt?
Yes No
If you have more than 3 requests, please attach additional pages as needed.
I certify that the information on this request form is correct to the best of my knowledge.
Submit request to:
OneCare Connect
Pharmacy Management Reimbursements
505 City Parkway West
Orange, CA 92868
Fax: 1-858-357-2556
Signature: __________________________
Date: _______________________________
Requestor’s Information
Complete this page ONLY if the person making this request is not the member.
Prescribers may make this request on behalf of the member. If the person making this request is another
individual (such as a family member or friend), that individual must be the member’s representative.
Attach documentation showing the authority to represent the member (a completed Authorization of
Representation Form CMS-1696 or written equivalent). For more information on appointing a
representative, contact Customer Service at 1-855-705-8823, 24 hours a day, 7 days a week. TDD/TTY
users should call 1-800-735-2929. You can also call 1-800-MEDICARE.
Name (First, Middle, Last):
Relationship to the Member:
Phone Number:
Fax Number: (if applicable)
Address where you get mail:
Address:
City, State, ZIP code:
City:
State: ZIP code:
Did you attach documentation
of representation?
Yes No
OneCare Connect is a health plan that contracts with both Medicare and Medi-Cal to provide
benefits of both programs to enrollees.
This information is available for free in other languages. Please call our Customer Service
number at 1-855-705-8823, 24 hours a day, 7 days a week. TDD/TTY users can call 1-800-735-
2929.
Esta información está disponible sin costo en otros idiomas. Por favor llame al Departamento de
Servicios para Miembros al 1-855-705-8823, las 24 horas al día, los 7 días de la semana.
Usuarios de la línea TDD/TTY deben llamar al 1-800-735-2929.
Thông tin này có sẵn miễn phí bằng những ngôn ngữ khác. Xin vui lòng liên lạc Văn Phòng Dịch
Vụ của chúng tôi ở số 1-855-705-8823, 24 giờ một ngày, 7 ngày một tuần. Thành viên sử dụng
máy TDD/TTY có thể gọi ở số 1-800-735-2929.
이 정보는 무료로 다른 언어로도 제공됩니다. 저희 고객 서비스 번호 1-855-705-8823으로 주 7일
24시간 전화주십시오. TDD/TTY 사용자는 번호 1-800-735-2929 로 전화하십시오.
،1-855-705-8823 هرﺎﻤﺷ ﺎﺑ نﺎﯾﺮﺘﺸﻣ تﺎﻣﺪﺧ ﺶﺨﺑ ﺎﺑ ﺎﻔﻄﻟ .ﺖﺳا دﻮﺟﻮﻣ ﺮﮕﯾد یﺎﮭﻧﺎﺑز ﮫﺑ ,ﯽﻧﺎﺠﻣ رﻮط ﮫﺑ تﺎﻋﻼطا ﻦﯾا
هرﺎﻤﺷ ﺎﺑ ﺪﻨﻧاﻮﺘﯿﻣ TDD/TTY ناﺮﺑرﺎﮐ .ﺪﯿﯾﺎﻤﻧ ﻞﺻﺎﺣ سﺎﻤﺗ ﮫﺘﻔھ زور 7 و زور ﮫﻧﺎﺒﺷ ﺖﻋﺎﺳ 24 لﻮط رد
.ﺪﻨﯾﺎﻤﻧ ﻞﺻﺎﺣ سﺎﻤﺗ 1-800-735-2929
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Prescription Drugs Payment Request Form (CalOptima)

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Completed 11 March 2021

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