Member Forms & Resources
Electronic Funds Transfer (EFT) Form
- Use this authorization agreement form for ACH debit to allow your plan to withdraw your monthly plan premium payment from your checking or savings account on the 10th of each month.
Medicare Member Designated Representative Form
- Complete this form if you want someone to act on your behalf. To prevent unauthorized use, these forms are posted on our Secure Member Portal.
Prescription Drug Forms
- Locate prescription drug forms including mail order and reimbursement forms.
Member Medical Reimbursement Form
- Return the completed form and applicable receipts to the address for your health plan listed in the attached document.
Prescription Drug Claim Form
- Request reimbursement for prescription drugs by completing this form.
Not yet a Member?
Access the Plan Finder to find plans available in your service area and compare benefits provided by Coventry. The choice is yours. When you compare costs, we think you’ll see the value that our plans offer.
find a plan
Coventry Health Care offers products across the county. Compare and find the best plan for you.
Find 2016 Plans >>
My Online Services
Access your health care information & manage your personal health with our wellness tools.
Login or Register Now >>