Coventry advantra prior authorization form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient’s name, member ID, phone number, date of request, date of birth, plan ID, and benefit information in the designated fields.
3. Fill in the requesting physician's details including DEA number, office phone, fax number, address, and tax ID number.
4. In the medication information section, select the appropriate diagnosis for opioid dependence or other conditions. Provide details on the requested Suboxone® Film dose and proposed length of treatment.
5. Indicate whether the patient will participate in a substance abuse counseling/treatment program and describe it briefly.
6. If applicable, complete the exception request section by providing a clinical rationale for exemption from utilization management requirements.
7. Finally, ensure all fields are completed clearly to avoid delays. Sign the form digitally before submitting.

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