Prescription Drug Information

Medicare "Part D" Prescription Drug Formulary

A drug formulary is a list of both generic and brand name prescription drugs that are covered by your prescription drug benefit. The formulary is managed by our Pharmacy and Therapeutics Committee, qualified pharmacists and doctors whose primary focus is offering safe, high-quality and cost-effective drugs. New drugs are added to the formulary periodically based on the latest medical research and some drugs may be removed periodically based on the findings and recommendations of the Pharmacy and Therapeutics Committee.


Learn about our Mail Order Pharmacy Program

Learn about Medication Therapy Management


Prescription Drug Benefits

Search Our Formulary

Click below for formularies and other Medicare Part D prescription drug benefits provided by Fidelis Care's Medicare Advantage and Dual Advantage plans.

Prescription Drug Formularies

Fidelis Dual Advantage, Fidelis Medicaid Advantage Plus, Fidelis Dual Advantage Flex, Fidelis Medicare Advantage Flex (HMO POS), and Fidelis Medicare $0 Premium (HMO)


2021 Formulary

2021 Formulary (PDF)


2020 Formularies

2020 Formulary (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.



    Drug Tiers

    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.

    Prior Authorization

    2021

    2021 Fidelis Care Medications Requiring Prior Authorization (PDF)


    2020


    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. 

    Step Therapy

    2021

    2021 Fidelis Care Step Therapy Criteria (PDF)


    2020

    2020 Fidelis Legacy Plan Step Therapy Criteria (PDF)


    Step Therapy is a process whereby prescriptions are filled using an effective and more affordable medication (Step 1). When appropriate, a more costly (Step 2) medication can be authorized if the Step 1 prescription is found to not be effective in treating your medical condition. 

    Formulary Transition Process

    When you have a drug that is not on our formulary, or if your ability to get the drug is limited, we will cover a temporary supply of the drug until you can switch to a drug we cover or you can request a formulary exception.

    Formulary Transition Policy (PDF)

    Pharmacy Network
    Pharmacy Network

    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.

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

    Requesting/Appealing Coverage Determinations

    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)


    Request for Coverage Redetermination of Prescription Drug Denials
    If Fidelis Medicare Advantage denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Prescription Drug Coverage to ask us for a redetermination. This form may be sent to us by mail or fax:

    Address:

    Fidelis Medicare Advantage 

    59-17 Junction Boulevard – 5th Floor 

    Elmhurst, New York 11373


    Fax Number: 
    1-877-882-5892

    Members  may ask us for an appeal through our website at www.fideliscare.org. Expedited appeal requests can be made by phone at 1-800-247-1447. Your prescribing doctor  may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. 

    Extra Help Program for Prescription Drug Costs

    Medicare Extra Help Program for Prescription Drug Costs


    If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.

    Level of extra help

    Fidelis Medicare Advantage Flex


    Plan 002

    Fidelis Medicare Advantage Flex


    Plan 007

    Fidelis Dual Advantage 


    Plan 001

    Fidelis Dual Advantage Flex


    Plan 006

    100%

    $0

    $0

    $0

    $0

    75%

    $2.70

    $1.80

    $5.40

    $5.60

    50%

    $5.40

    $3.70

    $10.80

    $11.20

    25%

    $8.20

    $5.50

    $16.20

    $16.9

    Monthly Premiums with Extra Help


    This table shows you what your monthly plan premium will be if you get extra help.



    Fidelis Medicare Advantage Flex, Fidelis Dual Advantage and Fidelis Dual Advantage Flex's premium includes coverage for both medical services and prescription drug coverage.

    If you aren't getting extra help, you can see if you qualify by calling:

    • 1-800-Medicare of TTY users call 1-877-486-2048 (24 hours a day/7 days a week),
    • Your State Medicaid Office, or
    • The Social Security Administration at 1-800-772-1213. TTY users should call 1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.


    Need to review the 2020 LIS Premium Chart?  Click HERE.

    Mail Order Prescription Drugs

    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.

    You’ll receive these benefits: 
    •  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



    Additional Information

    For a complete listing of plans in your service area, contact the plan.  Fidelis Care is contracted with Medicare for HMO, HMO D-SNP, and HMO-POS plans, and with the state Medicaid program. Enrollment in Fidelis Care depends on contract renewal.

    From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends and on federal holidays.

    Multi-Language insert (PDF)

    Non-Discrimination Notice (PDF)

    Privacy Policy

    H5599_21_22019

    Medication not Covered?

    Click HERE to request coverage for 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.  Approval is not guaranteed.  

    CVS Caremark

    Fidelis Care's pharmacy partner, CVS Caremark, offers tools that make managing your prescriptions easier.

    (By clicking this link, you will leave the Fidelis Care website.)