Request for Prescription Drug Coverage Determination

The purpose of this form is to request coverage of a medication that is not on your plan’s drug list or restricted in some way. Completion of this form provides information for the plan to decide whether to waive the restriction for you. We may or may not agree to waive the restriction for you. Members who complete this form may need clinical information, which can be provided by your medical prescriber.


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Fidelis Care
25-01 Jackson Avenue 
28th Floor
Long Island City, New York 11101

Fax: 877-882-5892

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1-800-247-1447
TTY: 771