Authorization and Exception Fax Forms
Beneficiaries seeking prior authorizations for a medication should speak with their physician. We encourage you to have your physician complete the forms below because we require specific clinical information and supporting documentation. All forms require the physician’s signature. Prior Authorization Forms submitted by beneficiaries without a physician’s signature will not be accepted.
You or your physician has the ability to fax a completed, signed form to Coventry Health Care 1-800-639-9158 in order to expedite processing. These forms can also be sent by mail to:
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.
Authorization and Exception Fax Forms
ACTIQ (fentanyl citrate)
ACTOS, DUETACT, ACTOPLUS MET, AVANDIA, AVANDAMET
ANTICOAGULANT
ANTIFUNGALS
ANTIHISTAMINES
APOKYN (apomorphine hydrochloride injection)
ARANESP
ARB
AVONEX, BETASERON, REBIF
BYETTA (Exenatide) Injection
Celebrex: COX II FORMULARY EXCEPTION REQUEST
COPAXONE
CYMBALTA
D.H.E. 45 & MIGRANAL (dihydroergotamine)
ENBREL (etanercept)
FORMULARY EXCEPTION
FORTEO (teriparatide)
FUZEON (enfuvirtide)
GENERAL PRIOR AUTHORIZATION
GLEEVEC (imatinib)
HEPATITIS B
HEPATITIS C
HUMIRA (adalimumab)
IMMUNOSUPPRESSANT
INSULIN CARTRIDGES AND PREFILLED PENS
IRESSA (gefitinib)
JANUVIA, JANUMET
LIPITOR
LYRICA
NEUPOGEN, LEUKINE, NEULASTA
ONGLYZA
OXYCODONE ER AND OXYCONTIN
PROTON PUMP INHIBITOR
PROVIGIL (modafanil)
QUANTITY LIMIT EXCEPTION
Red Blood Cell Stimulators
REVLIMID
SUBOXONE (buprenorphine/naloxone)
Symbyax
Symlin (pramlintide acetate)
TARCEVA (erlotinib)
TESTOSTERONE
THALOMID (thalidomide)
TRACLEER (bosentan)
XALATAN
XENAZINE
XOLAIR (omalizumab)
ZAVESCA (miglustat)
ZYPREXA (olanzapine)
CMS Approved N/A
CMS Document ID M0003C0002_09MAPDPDP_502_CVTYWEBg