Prior Authorizations & Exceptions

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Prior Authorization, Step Therapy, and Quantity Limits

Prior Authorizations

For drugs that require prior authorization, your doctor must complete the necessary form(s) below and include any clinical information and supporting documentation with the form(s). All forms require a physician's signature. Forms submitted without a physician's signature cannot be accepted. The prior authorization forms can be found using the link below.

Coverage Determinations

Under the Medicare Part D prescription drug benefit program, a beneficiary can request a coverage determination regarding the drug benefits they are entitled to receive. When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug. A beneficiary enrolled in a Part D plan may also request a cost-share 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.


You may contact us if you would like to request a coverage determination by completing the appropriate form listed below.  The timeframe for a coverage determination is dependent upon the medical situation surrounding the request. A request for an expedited coverage determination can be made orally by calling a Customer Service Representative, 24 hours a day, 7 days a week.

2016 Part D Prior Auth, Step Therapy, & Quantity Limits

2016 Prior Authorization Criteria
Each of the 2016 Plan Names listed in this document link to the appropriate 2016 Prior Authorization Criteria document. Please use the links listed in this document to access the specific criteria set that applies to your 2016 plan.
2016 Step Therapy Protocols
Each of the 2016 Plan Names listed in this document link to the appropriate 2016 Step Therapy Protocol document. Please use the links listed in this document to access the specific criteria set that applies to your 2016 plan.
2016 Quantity Limits
Access all of the quantity limits on First Health Part D (PDP) and Medicare Advantage Plan Part D prescription drugs.

2016 Prior Authorization and Exception Forms

2016 Prior Authorization and Exception Forms
Access to all of the Prior Authorization and Exception forms for Medicare Advantage and First Health Part D plans. All forms require the physician's signature and can be faxed to us as indicated on the form.

Coverage Determination Forms

Hospice Form
Online Forms
Request for Medicare Prescription Drug Coverage Determination Form
Request for Appeal/Redetermination of Medicare Prescription Drug Denial Form
Medicare Part D Coverage Determination Request Form for Physicians
Physicians may also submit written requests on the Coverage Determination Request Form for Physicians.  This form can be used to request a coverage determination or exception, submit a statement in support of an exceptions request, or attempt to satisfy a utilization management requirement.

Additional Information

Appointment of Representative Form
You, your prescribing physician, or someone you name may communicate with us on your behalf to request an initial determination or file a grievance or appeal. The person you name would be your “appointed representative.” You may name a relative, friend, advocate, doctor, or anyone else to act for you. Other persons may already be authorized under State law to act for you. If you want someone to act for you who is not already authorized under State law, then you and that person must sign and date a statement that gives the person legal permission to be your appointed representative.  Please contact your plan for more information.

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Y0022_PDPCCP_2013_4006_1202b Approved
CMS Approved Date: 02/08/2013
Page Last Updated: 12/29/2015

© 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.