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
4300 Cox Road
Glen Allen, VA 23060

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

For forms specific to Summit Health Plans, click here.
For forms specific to Vista Healthplans, click here.

Click here for 2010 Prior Authorization Criteria.

Authorization and Exception Fax Forms

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Coventry Health Care's product offerings span the country. Enter your 5-digit ZIP code below to locate individual plans (ZIP code lookup ):

Pharmacy Locator

Coventry Medicare

Coventry Health Care

Page Last Updated: 12/21/2009
CMS Approved Date: Pending CMS Approval
CMS Document ID: M0003C0002_09MAPDPDP_502_CVTYWEBg

Part D Prior Authorization Forms

Authorization and Exception Fax Forms

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Coventry Medicare

Coventry Health Care