Requesting Physician: Office Contact: Call Center ID: DEA Number


Chronic Schedule II Narcotics and Schedule III Narcotics with Hydrocodone
PRIOR AUTHORIZATION FORM
The following Coverage Policy applies to all non-Medicare health benefit plans.
Coverage Policy: Covered for the treatment of chronic pain when ALL of the following conditions are met:

Diagnosis of Cancer or Sickle Cell Anemia, OR

Under the age of 19, OR

Other Chronic Pain Diagnosis (must be pended to Pharmacist), OR

Completed Chronic Schedule II/ III Narcotics and Hydrocodone Agreement.
NOTE: Member must agree to be locked-in to one pharmacy for all medications.
Authorization renewals: Prior authorizations will be for a period of three months in order to comply with the Commonwealth’s
Controlled Substances Act. A Kasper Report must be reviewed every three months.
Reasons for Non-Coverage:
Violation of the Chronic Schedule II/ III Narcotics and Hydrocodone Agreement
PLEASE SEND COMPLETED FORM TO COVENTRY HEALTH CARE – PHARMACEUTICAL SERVICES
FAX:Q3 (877) 554-9139 PHONE: (877) 215-4098
Requesting Physician:
Call Center ID:
DEA Number:
Office Fax Number:
Office Address:
MEMBER INFORMATION
Patient Name:
Member ID#:
Office Contact:
Plan ID:
Benefit:
Phone Number:
DOB:
Date of Request:
MEDICAL INFORMATION
1.
2.
3.
4.
Please submit additional clinical notes and documentation as appropriate for your request.
Diagnosis: ______________________________
Does member have approved diagnosis?
YES  NO 
Is member under age 19?
YES  NO 
Did physician submit signed (by physician and
member) Schedule II/III and Hydrocodone agreement?
YES  NO 
Medication requested: ____________________________________________
Is this a new prescription?
 Yes  No, continuation request
Request Number from Kasper Report ______________________________
Date of Kasper Report ________________________________
ADDITIONAL COMMENTS:
PHYSICIAN’S SIGNATURE:
PHYSICIAN’S SPECIALTY:
9900 Corporate Campus Drive • Suite 1000 • Louisville, KY 40223
502-719-8600 • 888-470-0550 • www.coventrycaresky.com
CoventryCares of Kentucky is a Medicaid product of Coventry Health and Life Insurance Company
Revised 2-2-2015TK