Forms & Resources

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The First Health Part D member forms and resources are below for your convenience Additional Part D information and forms are available in the Coventry Prescription Drug section of the site.

For questions about any of these forms call First Health Part D Customer Service at 1-866-865-0662 (TTY/TDD 711 Telecommunications Relay Service), 24 hours a day, seven days a week.

FORMS & RESOURCES

Medicare Member Designated Representative Form
Complete this form if you want someone to act on your behalf. To prevent unauthorized use, these forms are posted on our Secure Member Portal.
Appointment of Representative Form
You can name a relative, friend, advocate, doctor, or someone else to be your appointed authorized representative. This will give that person the right and ability to act for you. This statement or form should be completed by supplying the requested information and should be sent to First Health Part D at:

First Health Part D
Coventry Health Care, Inc.
P.O. Box 7763
London, KY 40742
Electronic Funds Transfer (EFT) Form
Complete this form to have your First Health Part D premium deducted from your bank account each month.
Health, Allergy & Medication Questionnaire (HMQ)
Your answers to the following questions 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.
Mail Order Form
For Premier Plus and Essentials Members Only:
First Health Part D Premier Plus and First Health Part D Essentials Members:You can choose to have your prescriptions filled and mailed directly to your home or office using our mail service pharmacies. Follow the instructions on the order form to expedite service. When getting a new prescription, be sure to ask your doctor to write your prescription for a 90-day supply and be sure that your doctor signs and dates all new prescriptions. Mail Order services are not covered for First Health Part D Value Plus members.
Prescription Drug Claim Form
To Submit Claims:

Express Scripts, Inc.
ATTN: Coventry Med D
P.O. Box 2860
Clinton, IA 52733-2860
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.
Member Request for Medicare Prescription Drug Coverage Determination
Under the Medicare Part D prescription drug benefit program, a Part D plan beneficiary can request a coverage determination, including a request for a tiering or formulary exception. A request can also be made on behalf of the beneficiary by the beneficiary’s appointed representative or the beneficiary’s prescribing physician. A request for a standard coverage determination must be made in writing and faxed to: (800) 639-9158 or mailed to:

First Health Part D
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 for the hearing or speech impaired or in writing.
Member Request for Medicare Prescription Drug Coverage Redetermination

An appeal or "redetermination" is any of the procedures that deal with the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug. You must contact us if you would like to request a coverage redetermination by completing this form.

Physician Prior Authorization Forms
Beneficiaries seeking prior authorization for a medication should speak with their physician. We encourage you to have your physician complete these forms because we require specific clinical information and supporting documentation. All forms require the physician's signature. Prior Authorization Forms submitted by beneficiaries without a physician's signature will not be accepted.

You or your physician has the ability to fax a completed, signed form to Coventry Health Care 1-800-639-9158 in order to expedite processing. These forms can also be sent by mail to:

Medicare Prescription Drug Plan
P.O. Box 7773
London, KY 40742
Medicare Part D Vaccines
Information on Medicare Part D Vaccines.

Medicare Part D Prescription Drug Benefits

Find more information about First Health Part D benefits.

Page Last Updated: 08/26/2014
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.