Coventry Care Medicaid Form PDF Details

Coventry Care Medicaid is a healthcare program that provides coverage for low-income individuals and families. The program is administered by the state of Connecticut and provides benefits such as health insurance, prescription drugs, dental care, and vision services. In order to qualify for Coventry Care Medicaid, applicants must meet certain income requirements. The application process is also relatively simple and can be completed online or by mail. If you are looking for affordable health insurance coverage, Coventry Care Medicaid may be a good option for you. The program offers a variety of benefits, including health insurance, prescription drugs, dental care, and vision services. In addition, the application process is simple and can be completed online or by mail. eligibility requirements vary depending on

QuestionAnswer
Form NameCoventry Care Medicaid Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesc085139 coventry care medicaid form

Form Preview Example

Preferred Drug List Prior Aut horizat ion Form

CoventryCares of West Virginia, Inc.

500 Virginia Street, East, Suite 400

Charleston, WV 25301

Fax: 1-855-799-2555

Phone: 1-877-215-4100

www.coventrycareswv.com

 

 

 

 

 

 

Pat ient Name (Last )

(First )

(M I)

WV M edicaid 11-Digit ID #

Dat e of Birt h (M M / DD/ YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

Prescriber Nam e (Last )

 

(First )

 

 

(M I)

 

 

 

 

 

 

Prescriber Addr ess (St reet )

 

(Cit y)

 

(St at e)

(Zip)

 

 

 

 

 

 

Prescriber 10-Digit NPI#

 

Phone # (111-222-3333)

 

Fax # (111-222-3333)

 

 

 

 

 

 

 

 

 

 

 

 

 

Pharmacy Name (if applicable)

 

 

 

 

 

 

 

 

 

 

 

Pharmacy Address (St r eet )

 

(Cit y)

 

(St at e)

(Zip)

 

 

 

 

 

 

Pharmacy 10-Digit NPI#

 

Phone # (111-222-3333)

 

Fax # (111-222-3333)

 

 

 

 

 

 

 

Confident ialit y Not ice: This document cont ains confident ial healt h informat ion t hat is prot ect ed by law . This informat ion is int ended only for t he use of t he individual or ent it y named above. The int ended r ecipient of t his informat ion should dest r oy t he informat ion aft er t he purpose of it s t ransmission has been accomplished or is responsible for prot ect ing t he informat ion from any furt her disclosur e. The int ended recipi ent is prohibit ed fr om disclosing t his informat ion t o any ot her part y unless required t o do so by law . If you are not t he int ended recipient , you are hereby not ified t hat any disclosure, copying, dist ribut ion, or act ion t aken in reliance on t he cont ent s of t hese document s is st rict ly prohibit ed. If you have received t his informat ion in error , please not ify t he sender immediat ely by t elephone at (877) 215-4100 and arrange for t he ret urn or dest ruct ion of t hese document s. Thank you.

Im portant Notes:

Preaut horizat ion for medical necessit y does not guarant ee payment .

 

 

 

The use of pharmaceut ical samples w ill not be considered w hen evaluat ing t he members’ m edical condit ion or prior pr escript ion hist ory for dr ugs t hat require prior

 

aut horizat ion .

 

 

 

 

 

 

 

Drug Nam e

 

St rengt h

Rout e of Administ rat ion

 

 

 

 

Direct ions

 

Diagnosis

ICD Diagnosis Code (if available)

 

 

 

 

Has t he pat ient experienced t reat m ent failure w it h t he pref erred product (s)?

o Yes

o No

If yes, list or explain. If no, furt her comm ent is opt ional.

 

 

 

 

 

Does t he pat ient have a condit ion t hat prevent s t he use of t he pref erred pr oduct (s)?

o Yes

o No

If yes, list t he condit ion(s). If no, furt her comm ent is opt ional.

 

 

 

 

 

 

 

 

 

Page 1 of 2

 

Rev. 04/ 02/ 2013

Preferred Drug List Prior Aut horizat ion Form

Is t here a pot ent ial drug int eract ion w it h t he pat ient ’s current medicat ion and t he pref erred product (s)?

 

o Yes

o No

If yes, list or explain.. If no, furt her com ment is opt ional.

 

 

 

 

 

 

 

 

Has t he pat ient experienced i nt olerable si de ef fect s w hile on t he pref erred product (s)?

 

o Yes

o No

If yes, list or explain.. If no, furt her com ment is opt ional.

 

 

 

 

 

 

 

 

 

 

 

 

 

Attestation: Your signat ure (manually or elect r onically) cert ifies t hat t he above request is medically necessary, does not

 

o Check here for elect ronic

exceed t he medical needs of t he m em ber, and is docum ent ed in your medical records. M edical/ Phar macy records m ust be

 

 

 

 

made available upon r equest .

 

signat ure

 

 

 

 

 

Prescriber or Pharmacist Signat ure:

 

Dat e:

 

 

(M M / DD/ YYYY)

 

 

 

 

 

 

 

 

 

Page 2 of 2

Rev. 04/ 02/ 2013

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