If you paid for a service that you think the Alliance should cover, you will need to complete a Member Request for Reimbursement Form and tell the Alliance in writing why you had to pay. You will need to include a copy of the itemized bill and proof of payment (such as receipts) with your request. The Alliance will review your request to find out if you can get money back. The Alliance will accept and review requests for reimbursement for a health expense that is received within 180 calendar days after the date the bill was paid.
Please use one (1) form for each health expense you are asking the Alliance to reimburse to you.
To request for a reimbursement please complete the form below:
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To request for a pharmacy reimbursement (Alliance Medi-Cal members dates of service prior to Saturday, January 1, 2022), please complete the form below:
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Alliance Medi-Cal member dates of service on or after Saturday, January 1, 2022, please call Medi-Cal Rx toll-free at 1.800.977.2273