Prescription Drug Information

2021 Formularies

2021 Formulary (PDF)

Part B Diabetic Meters and Test Strips (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.

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

2021

2021 Fidelis Care Medications Requiring Prior Authorization (PDF)

Medication Request Form (PDF)

2021

2021 Fidelis Care 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

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.

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