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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 www.cvty.com. PLEASE SEND COMPLETED FORM TO COVENTRY HEALTH CARE ­ PHARMACEUTICAL SERVICES FA X:Q 3 ( 8 7 7 ) 5 5 4 - 9 1 3 9 P H O N E : ( 8 7 7 ) 2 1 5 - 4 0 9 8 Requesting Physician: Call Center ID: Office Fax Number: Office Address: MEMBER INFORMATION Patient Name: Member ID#: MEDICATION INFORMATION Tax ID Number: Office Contact: Plan ID: Benefit: Phone Number:

DOB: Date of Request: May 4, 2008

Drug Requested: 1. Dose: 2. Diagnosis: List other formulary agents tried: (include all office notes and supporting documentation) Drug: ________________ Date(s) used: __________ Outcome: __________________ 3. Drug: ________________ Date(s) used: __________ Outcome: __________________ 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.)

Duration:

4.

Physician's Signature:

CHCH 2025-2 (03/08)

Visit our Website at WWW.CVTY.COM

Fax Confidentiality Notice: The information contained in this transmission is confidential, proprietary or privileged and may be subject to protection under the law, including the Health Insurance Portability and Accountability Act (HIPAA). The message is intended for the sole use of the individual or entity to whom it is addressed. If you are not the intended recipient, you are notified that any use, distribution or copying of the attached material is strictly prohibited and may subject you to criminal or civil penalties. If you received this transmission in error please notify us immediately by telephone at 1-877-215-4100.

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