Prescription Drug Forms
Coventry 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 FORMS
Mail Order Form
- Use this form to order medication through our mail-order service (EXPRESS SCRIPTS BY MAIL). If you need additional information or assistance please call Pharmacy Customer Service at the phone number on your ID card.
- If you wish to order prescriptions online please go to www.express-scripts.com to register and order.
Prior Authorization Forms
- Locate available prior authorization 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
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.
Health, Allergy & Medication Questionnaire (HMQ)
- Your answers 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 quantity limit information, step therapy information and prior authorization and step therapy fax forms.
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