Member Forms & Resources

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Electronic Funds Transfer (EFT) Form

Use this form to allow your plan to withdraw your monthly plan premium payment from your checking or savings account on the 10th of each month.
Prescription Drug Forms
Locate prescription drug forms including mail order and reimbursement forms.
New Member
Medicare Transition of Care Form

In order to facilitate continuity of care for scheduled surgeries or planned procedures, or complex or chronic conditions for which you or your dependents are undergoing regular treatment, please complete the information on this form.

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.
Part D 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.
Prescription Drug Claim Form
Request reimbursement for prescription drugs by completing this form.

Page Last Updated: 12/17/2014
CMS Approved Date: Approved 02/08/2013
CMS Document ID: Y0022_PDPCCP_2013_4006_1202b

© Copyright 2008-2015 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.