Fidelis Medicare Advantage and Dual Advantage Plans

2020 Formulary

2020 Formulary (PDF)

2020 Formulary Changes (PDF)

Formulario 2020 (PDF)

Фармакологический справочник на 2020 г. (PDF)

2020年處方一覽表 (PDF)

• If a drug is not covered in the way you would like it to be covered, you can ask us to make an “exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision. Asking for coverage of a drug that is not on the Prescription Drug Formulary, also called the Drug List, is sometimes called asking for a “formulary exception.” When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. The information can be submitted by phone, fax, mail or electronically. We will then consider your request.

Part B Diabetic Supplies (PDF)

The price of a drug is determined by what “tier” it is on within your formulary. A generic drug may appear on a “preferred tier,” while a brand-name drug may appear on a “non-preferred tier.” Medicine listed on a non-preferred tier may be more expensive than those on a preferred tier. You can reduce how much you pay for prescription drugs by using preferred tier drug. You should talk to your primary care physician about preferred tier options available to you.

Generic Substitution
If Fidelis Care receives a prior authorization or exception request, the medication requested will be generically substituted when an authorized, AB rated equivalent generic is available, unless the request specifically indicates that the brand name is being requested (e.g. Dispense as Written, brand only, etc.), rejections in prescription claims history are for brand, or supporting documentation indicates brand is being prescribed or why generic is not an appropriate treatment option.

Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. If your drug needs this step, you or your doctor will need to ask for and get advance approval from Fidelis Care to cover the drug. 

• 2020 Fidelis Legacy Plan Medications Requiring Prior Authorization (PDF)

Medication Request Form (PDF)

Medication Request Form - Spanish (PDF)

• 2020 Fidelis Legacy Plan Step Therapy Criteria (PDF)

Formulary Transition Policy (PDF)

Fidelis Care has contacts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area. There are over 4,400 pharmacies located in New York State that participate in our pharmacy network and over 64,400 network pharmacies nationwide.

• View or download the Fidelis Care Provider and Pharmacy Directory for your county on our Medicare Resources page. 
• To find a pharmacy near you, use the Fidelis Care Find a Doctor tool

Visit the CVS Caremark website (by clicking on this link, you will leave the Fidelis Care website) for more information or to register. 

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.  

You can submit this form in two ways:  

- Option 1. (Recommended) complete the online form by following the link below. 

- Option 2. Download the PDF hard copy and send to the address at the bottom of this document.

1. Online Form: Medication Request Form

2. Paper Form: Medication Request Form (PDF)

• Medicare Prescription Drug Denial Request for Redetermination (PDF)
• Medicare Prescription Drug Denial Request for Redetermination Online Form

2020 LIS Premium Chart (PDF)

This chart shows monthly program premiums for people who get extra help from Medicare to pay for their prescription drug costs. 

Best Available Evidence

The Centers for Medicare and Medicaid Services (CMS) created the Best Available Evidence (BAE) policy in 2006 for Part D plans that administer the Low-Income Subsidy (LIS) program, including the reduction of cost sharing for subsidy-eligible individuals.

This policy requires plans to accept certain forms of documentation for a beneficiary’s eligibility for LIS, to change the beneficiary’s cost-sharing levels in the plans system based on that documentation, and for LIS beneficiaries to submit to CMS requests for correction of the data in their system if the changes do not occur as a result of routine State reporting.

More information about Best Available Evidence (Please note that by clicking on this link, you will leave Fidelis Care’s website).

Mail Order Enrollment Form (PDF)

You can have your medications delivered directly to your home, so you don’t have to make unnecessary trips to the local pharmacy. Not only does this service save you time, it also saves you money. Typically, you can get a 90-day supply of your medication for the price you would pay for three 30-day supplies picked up at the pharmacy counter.

•  Cost savings:  One 90-day supply may cost less than three 30-day supplies at a retail pharmacy
•  Greater convenience: At-home delivery at no extra cost, and easy refills online or by phone
•  Quality and safety: Dedicated pharmacists checking each and every order
•  Added value: 24/7 access to pharmacists, and alert messages by e-mail, text, or phone

Mail Order Durable Medical Equipment

For your convenience, Fidelis Care offers direct mail options to fill your durable medical equipment needs. These providers offer a wide range of supplies such as diabetes test strips, bladder control pads, bandages, and more.

• Byram Healthcare. Call 1-877-902-9726, and a customer service representative will assist you with your order. You also can download order forms and fax them to 1-866-811-4500. Online reordering is available at Byram’s website, www.byramhealthcare.com.
• Edgepark Medical Supplies. Call 1-800-321-0591 or visit www.edgepark.com to place an order.

Clicking the links above will cause you to leave the Fidelis Care website