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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  • 8 check-boxes
  • 44 other fields

Country of origin: US
File type: PDF

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H5433_PD16_37 Accepted (10/07/15)
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 (HMO SNP)
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 1-877-412-2734, 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 (HMO SNP) is a Medicare Advantage organization with a Medicare Contract and a contract
with the California Medi-Cal (Medicaid) program. Enrollment in OneCare depends on contract renewal.
This information is available for free in other languages. Please call our Customer Service number at 1-
877-412-2734, 24 hours, 7 days a week, for additional information. (TDD/TTY users should call 1-800-
735-2929).
Esta información está disponible gratis en otros idiomas. Para más información, por favor llame al
Departamento de Servicios para Miembros al 1-877-412-2734, las 24 horas al día, los 7 días de la
semana. (Usuarios de la línea TDD/TTY pueden llamar al 1-800-735-2929).
Thông tin này cũng có sẵn miễn phí bằng những ngôn ngữ khác. Xin vui lòng liên lạc Văn Phòng Dịch
Vụ của chúng tôi qua số điện thoại 1-877-412-2734 để biết thêm chi tiết. (Thành viên sử dụng máy
TDD/TTY có thể liên lạc qua số 1-800-735-2929). Quý vị có thể liên lạc 24 giờ một ngày, 7 ngày một
tuần.
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Prescription Drugs Payment Request Form (CalOptima)

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Completed 11 March 2021

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