Form Chch 2025-3 Prior Authorization Medication - Coventry Health Care

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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: ________________________________________________________________

Dose: ______________________

Duration: ______________________

2. Diagnosis: ________________________________________________________________

List other formulary agents tried:

(include all office notes and supporting documentation)

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.)

__________________________________________________________________________

Physician’s Signature: _______________________________________________________________

CHCH 2025-3 (04/10)

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