Prescription Drug Forms

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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

www.express-scripts.com
If you wish to order prescriptions online please go to www.express-scripts.com to register and order.
Mail Order Form
With the mail order pharmacy service through Express Scripts, 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 (EXPRESS SCRIPTS BY MAIL).  If you need additional information or assistance call Pharmacy Customer Service at the phone number on your ID card.


Reimbursement Forms

Prescription Drug Claim Form

Request reimbursement for prescription drugs by completing this form.

Vaccine & Administration (Injection) Claim Form
This claim form is for reimbursement of covered Part D vaccines and their administration (injection). Please consult your Evidence of Coverage for specific coverage information.


Coverage Determination Forms

Hospice Form
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 or TTY 711 Telecommunications Relay Service for the hearing or speech impaired
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) 536-6767 or TTY 711 Telecommunications Relay Service for the hearing or speech impaired
Appeals and Grievances
Locate additional information about appeals and grievances.


Additional Information

Health, Allergy & Medication Questionnaire (HMQ)
Your answers to the following questions will help protect you against potentially harmful drug interactions and side effects. Express Scripts will alert your pharmacist about possible drug allergies and interactions that can be harmful. To best serve you, Express Scripts needs you to answer the questions in this questionnaire.
Prescription Drug Benefits
Find more prescription drug benefit information and forms, including prior authorization and step therapy fax forms.

Medicare Part D Prescription Drug Benefits

Click here to find more information about Coventry's Part D benefits.

You may have the option to use mail-order. For mail-order, you can get prescription drugs shipped to your home through the network mail-order delivery program. Typically, mail-order drugs arrive within 9 to 12 days. Please call us if you do not receive your mail-order drugs within this timeframe. Coventry members please call the phone number listed on the back of your member ID card

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Page Last Updated: 09/28/2014
CMS Approved Date: Approved 02/08/2013
CMS Document ID: Y0022_PDPCCP_2013_4006_1202b

© Copyright 2008-2014 Coventry Health Care

Coventry Health Care is a Coordinated Care plan with a Medicare contract. First Health Part D is a Medicare-approved Part D sponsor. Enrollment in our plans depends on contract renewal.