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:
Fidelis Medicare Advantage
59-17 Junction Boulevard – 5th Floor
Elmhurst, New York 11373
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.