Drug Prior Authorization Forms
To submit a Medicare Part D Drug Coverage Determination or Exception request, please refer to the Pharmacy Part D Initial Coverage Determination, Exception Requests, or Continuous Glucose Monitor and Supplies section on this page.
Continuous Glucose Monitors and Supplies
To submit a Coverage Determination or Exception request, please refer to the Pharmacy Part D Initial Coverage Determination, Exception Requests, or Continuous Glucose Monitors and Supplies section on this page.
Medicare Part B Medical Drugs
Medicare Part B Medical Drugs may require a Prior Authorization depending on the drug.
Sentara Medicare Part B Preferred Step Therapy Drug List
Sentara Medicare Part B Drug Policy Criteria
To submit a request for a Part B Medication that requires Prior Authorization, please Fax the Medication Precertification Request form:
Form can be submitted to:
Sentara Health Plans
Fax: 1-844-895-3232
Sentara Medicare Medical Medication Precertification Request
If you do not find your drug on either the links list above under Medicare Part B section, access the Prior Authorization Lookup Tool (PAL) to verify if the drug requires a Prior Authorization.
Pharmacy Part D Initial Coverage Determination, Exception Requests, or Continuous Glucose Monitor and Supplies
A coverage determination is a decision made by our plan (not the pharmacy) about your Part D prescription drug benefits. To ask for a coverage determination, fill out the following form (provided in English and Spanish):
Sentara Medicare Part D Drug Coverage Determination Form
Coverage Determination forms can be submitted to:
Sentara Health Plans
Appeals and Grievances
PO Box 62876
Virginia Beach, VA 23466
Fax: 1-800-750-9692
Pharmacy Redetermination or Part D drug Appeal
If Sentara Health Plans denies a request for Medicare prescription drug coverage, you may request a redetermination or appeal. To initiate a redetermination, download and fax in the following form (provided in English and Spanish):
Medicare Part D Redetermination Request (Appeal) Form
Redetermination forms can be submitted to:
Sentara Health Plans
Appeals and Grievances
PO Box 62876
Virginia Beach, VA 23466
Fax: 1-866-472-3920