Prescription Drug Forms
Altius Advantra Prescription Drug Forms
Below are forms and information pertaining directly to your prescription drug plan. Additional Part D information and forms are available in the Coventry Prescription Drug section of the site.
Prescription Drug Order Information
My Online Services
- If you wish to order prescriptions online please go to My Online Services to register and order.
Mail Order Form (English / Spanish)
- With the mail order pharmacy service through CVS, you can arrange to have your maintenance drugs mailed to you each month for as long as your doctor’s prescription is valid. Use this form to order medication through our mail order service (CVS BY MAIL). If you need additional information or assistance call Pharmacy Customer Service at the phone number on your ID card.
Prescription Drug Claim Form (English / Spanish)
Request reimbursement for prescription drugs by completing this form.
Coverage Determination Forms
Request for Medicare Prescription Drug Coverage Determination Form
- Download and print PDF to submit - A request for a standard coverage determination can be made in writing and faxed to (800) 639-9158 or mailed to Coventry Health Care Coverage Determinations, P.O. Box 7773, London, KY 40742
- A request for an expedited coverage determination can be made by calling (800) 551-2694 (TTY: 711)
Request for Appeal/ Redetermination of Medicare Prescription Drug Denial
- Download and print PDF to submit - A request for a coverage redetermination can be made in writing and faxed to (800) 535-4047 or mailed to Coventry Health Care Coverage Redeterminations, P.O. Box 7773, London, KY 40742
- A request for an expedited coverage redetermination can be made by calling (800) 536-6167 (TTY: 711)
Appeals and Grievances
- Locate additional information about appeals and grievances.
Prescription Drug Benefits
- Find more prescription drug benefit information and forms, including prior authorization and step therapy fax forms.
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