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 (English / Spanish)
- Use this form to order medication through our mail-order service (CVS BY MAIL). If you need additional information or assistance please call Pharmacy Customer Service at the phone number on your ID card.
My Online Services
- If you wish to order prescriptions online please go to My Online Services to register and order.
Prior Authorization Forms
- Locate available prior authorization forms.
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) 536-6767 (TTY: 711)
Appeals and Grievances
- Locate additional information about appeals and grievances.
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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