Prescription Drug Forms

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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.


Reimbursement Forms

Prescription Drug Claim Form (English / Spanish)
Request reimbursement for prescription drugs by completing this form.


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 (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.


Additional Information

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

Find more information about Coventry's Part D benefits.

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 7 to 14 days. Please call us if you do not receive your mail-order drugs within this timeframe.

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Y0022_PDPCCP_2013_4006_1202b Approved
CMS Approved Date: 02/08/2013
Page Last Updated: 12/15/2015

© Copyright 2008-2016 Coventry Health Care

Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with State Medicaid programs. Enrollment in our plans depends on contract renewal.