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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'Requesting Physician' section, including your Call Center ID, Office Contact, Tax ID Number, Plan ID, Office Fax Number, Benefit, Phone Number, and Office Address.
In the 'MEMBER INFORMATION' section, enter the Patient Name, DOB, Member ID#, and Date of Request.
Proceed to the 'MEDICATION INFORMATION' section. Select the drug requested (Lyrica, Cymbalta, or Savella) and provide details of past treatment trials including specific drugs used and their therapeutic outcomes.
Indicate whether the member failed non-pharmacologic therapy by selecting YES or NO. If applicable, list therapies tried in the provided space.
Finally, ensure you sign in the designated area for the Physician’s Signature before submitting your completed form.

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What is a pre-auth form?

Our Health Plan and Medical Services Division is primarily comprised of our traditional health plan commercial risk, Medicare Advantage and Medicaid products.

Is Aetna the same as Coventry?

Coventry Health Care Inc., often referred to as Coventry, is a national health insurance company. The diversified company is dedicated to providing affordable and high-quality health insurance solutions to its customers.