PRIOR AUTHORIZATION MEDICATION – GENERAL REQUEST FORM
Coverage Policy:
For medications that require prior authorization, when the only information required is a
diagnosis, and previous treatment trials and failures. When requesting a medication that requires additional, more
specific information (clinical notes, lab values, test results, etc) please use the prior authorization form specific to that
medication (eg: Byetta, Procrit, testosterone, TZDs).*
Requests meeting the following criteria will be considered:
•
Use for an FDA-approved indication
•
Intolerability or failure to other medications used to treat the stated diagnosis, after an adequate trial
* A listing of all drugs that require prior authorization can be found at
PLEASE SEND COMPLETED FORM TO COVENTRY HEALTH CARE – PHARMACEUTICAL SERVICES
F A X : ( 87 7) 5 5 4- 91 37
PH O N E: ( 8 77) 21 5- 41 00
______________________
Requesting Physician:
_______________________
Office Contact:
_____
______________
___
_______________
Call Center ID:
Tax ID Number:
Plan ID:
Benefit:
______________________
Office Fax Number:
______________________
Phone Number:
__________________________________________________________________________
Office Address:
MEMBER INFORMATION
Patient Name: ______________________
DOB: ______________________
Member ID#:______________________
Date of Request: ______________________
MEDICATION INFORMATION
Drug Requested: ________________________________________________________________
1.
Dose: ______________________
Duration: ______________________
2. Diagnosis: ________________________________________________________________
List other formulary agents tried:
(include all office notes and supporting documentation)
Drug: __________________ Date(s) used: ____________ Outcome: ____________________
Drug: __________________ Date(s) used: ____________ Outcome: ____________________
3.
Drug: __________________ Date(s) used: ____________ Outcome: ____________________
Drug: __________________ Date(s) used: ____________ Outcome: ____________________
Other supporting information:
(Supporting clinical documentation is particularly important when
requesting an exception to coverage criteria for reasons of medical necessity.)
__________________________________________________________________________
4.
__________________________________________________________________________
__________________________________________________________________________
Physician’s Signature: _______________________________________________________________
CHCH 2025-3 (04/10)
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