Prescription Drug Forms

Prescription Drug Forms Section Banner Image

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.


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 to register and order.
Prior Authorization Forms
Locate available prior authorization forms.

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
  • 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 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.

Medicare Part D Prescription Drug Benefits

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

find a plan

Coventry Health Care offers products across the county. Compare and find the best plan for you.

Find 2014 Plans >>

More Information
Get Adobe Reader

Page Last Updated: 12/30/2013
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.