Part D Prior Authorization Forms

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Part D Prior Authorization & Step Therapy Forms for Coventry's Medicare Advantage and First Health Part D Plans

For drugs that require prior authorization, your doctor must complete the necessary form(s) 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.

You or your physician has the ability to fax a completed, signed form to Coventry Health Care at 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

Please be sure the appropriate authorization form is completed in full prior to mailing.  For more information, refer to your Evidence of Coverage.

Authorization and Exception Fax Forms

2015 Forms


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Page Last Updated: 03/13/2015
CMS Approved Date: Pending 02/08/2013
CMS Document ID: Y0022_PDPCCP_2013_4006_1202b

© Copyright 2008-2015 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.