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 1-844-233-1938 (TTY:711), 24 hours a day, seven days a week.


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.
Electronic Funds Transfer (EFT) Form
Complete this form to have your First Health Part D premium deducted from your bank account each month.
Mail Order Form (English / Spanish)
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, ask your doctor to write your prescription for a 90-day supply and be sure that your doctor signs and dates all new prescriptions.
Prescription Drug Claim Form (English / Spanish)
To Submit Claims:

Aetna Pharmacy Management
PO Box 52446
Phoenix, AZ 85072-2446
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 (TTY: 711).
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 Prescription Drug Benefits

Find more information about First Health Part D benefits.

Y0022_PDPCCP_2013_4006_1202b Approved
CMS Approved Date: 02/08/2013
Page Last Updated: 03/09/2016

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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.