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 found below must be either mailed or faxed to:

Mail:
Medicare Prescription Drug Plan
4300 Cox Road
Glen Allen, VA 23060

Fax:
Refer to the fax number indicated on the form.

Coverage Determinations

Under the Medicare Part D prescription drug benefit program, a Part D plan beneficiary can request a coverage determination regarding the drug benefits they are entitled to receive. When Coventry makes a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what the beneficiary's share of the cost is for the drug. A Part D plan beneficiary 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.

Part D Prior Authorizations & Exception Forms

2009 Prior Authorization Criteria: Prior authorization criteria for Advantra Rx (PDP) from Coventry Health Care and Advantra (HMO/PPO/POS) from Coventry Health Care.

2010 Prior Authorization Criteria: Prior authorization criteria for Advantra Rx (PDP) from Coventry Health Care and Advantra (HMO/PPO/POS) from Coventry Health Care.

AdvantraRx (PDP) Part D Prior Authorization & Exception Forms: Access to all of the Part D Prior Authorization and Exception forms. All forms require the physician's signature and can be faxed to Coventry Health Care as indicated on the form

Medicare Advantage Plan Part D Prior Authorization & Exception Forms: Access to all of the Medicare Advantage Plan Part D Prior Authorization and Exception forms. All forms require the physician's signature and can be faxed to Coventry Health Care as indicated on the form

Quantity Limits: Access all of the quantity limits on AdvantraRx (PDP) and Medicare Advantage Plan Part D prescription drugs.

2010 Step Therapy Protocols

Access the AdvantraRx (PDP) and Medicare Advantage Part D Plan step therapy protocols:

Coverage Determination Forms

AdvantraRx (PDP) Stand-Alone Medicare Prescription Drug Plan

HMO, PPO and POS Plans

Request for Medicare Prescription Drug Coverage Determination Form
For all HMO, PPO and POS plans (except Summit Health Plans and Vista Healthplans), complete the form located above and send to:
MAPD Pharmacy Clinical Call Center
3721 TecPort Drive
P.O. Box 67103
Harrisburg, PA 17106-7103
Summit Health Plans Request for Medicare Prescription Drug Coverage Determination Form
Vista Health Plans Request for Medicare Prescription Drug Coverage Determination Form

Medicare Part D Coverage Determination Request Form for Providers: 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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Page Last Updated: 11/11/2009
CMS Approved Date: Pending CMS Approval
CMS Document ID: M0003C0002_09MAPDPDP_502_CVTYWEBd

Prior Authorizations & Exceptions