Pharmacy Services

Acaria Health Specialty Medication Referral Form (PDF)

Billing Medicaid Pharmacy LTC/SNF Claims (PDF)

CVS Caremark Specialty Pharmacy Fax Enrollment Form (PDF)

HealthierLife (HARP) Coverage and the Behavioral Health Carve-in: July 2, 2018 (PDF)

Medicaid, Child Health Plus, and HealthierLife Formulary Changes Effective September/October 1, 2018 (PDF)

Medicaid, Child Health Plus, and HealthierLife Formulary Changes Effective August 1, 2018 (PDF)

Medicaid, Child Health Plus, and HealthierLife Formulary Changes Effective July 1, 2018 (PDF)

Medicaid, Child Health Plus, and HealthierLife Formulary Changes for April/May 2018 (PDF)

Medicaid, Child Health Plus, and HealthierLife Formulary Changes for January 2018 (PDF)

Notice on the 2018 Flu Season Medications (PDF)

Qualified Health Plans and Essential Plans Formulary Changes for 2018 (PDF)

Requesting Synagis for Fidelis Care Members (PDF)

Child Health Plus (CHP), HealthierLife (HARP), and Medicaid Managed Care

2018 Formulary (PDF)

Formulary Changes (PDF)

Quick reference list (PDF)

Medicaid, Child Health Plus, and HealthierLife Formulary Changes Effective August 1, 2018 (PDF)

Medicaid, Child Health Plus, and HealthierLife Formulary Changes Effective July 1, 2018 (PDF)

Metal-Level Products

2018 Formulary (PDF)

Formulary Changes (PDF)

2017 Formulary (PDF)

Essential Plan

2018 Formulary (PDF)

Formulary Changes (PDF)

2017 Formulary (PDF)

Metal-Level Products and Essential Plans Formulary Changes: Effective January 1, 2018 (PDF)

Fidelis Dual Advantage, Fidelis Medicaid Advantage Plus and Fidelis Dual Advantage Flex 

2019 Formulary (PDF)

Prior Authorization (PA) Criteria (PDF)

Step Therapy Criteria (PDF)

2018 Formulary (PDF)

Prior Authorization (PA) Criteria (PDF)

Fidelis Medicare Advantage Flex (HMO POS) and Fidelis Medicare $0 Premium (HMO)

2019 Formulary (PDF)

Prior Authorization (PA) Criteria (PDF)

Step Therapy Criteria (PDF)

2018 Formulary (PDF)

Prior Authorization (PA) Criteria (PDF)

Medication Request Form for Medicaid, CHP, and Qualified Health Plans (PDF)

Opioid Prior Authorization Form (PDF)

Hepatitis C Prior Authorization Form (PDF)

Medicare Medication Request Form (PDF)

Medicare Electronic Drug Coverage Determination Form

New York State Department of Health standardized prior authorization form (PDF)

Specialty Medication Prior Authorization Criteria: Medicaid, CHP, and Metal-Level Plans (PDF)

Specialty Medication Prior Authorization Criteria: Medicare (PDF)