Request for Supplemental Prescription Drug Coverage

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 Legacy Plan
59-17 Junction Boulevard
5th Floor
Elmhurst, New York 11373

Fax: 877-882-5892

By phone:

1-800-247-1447

TTY: 771