Provider Quality

Fidelis Care’s Pharmacy Services would like to provide clarification on how medications are covered under member’s medical and pharmacy benefits.

Medications Covered Under Fidelis Care Medical Benefit

• Physician Administered Drugs – medications administered to a member during an outpatient visit.
  • Providers obtain medication via “buy-and-bill” or shipment to their practice site from a vendor of their choosing.
  • Coverage is dictated by Fidelis Care Authorization Grids, Prior Authorization Lookup Tool and/or Evolent Specialty Services (formerly NCH) Authorization Grids (Oncology Regimen Specific).
  • Medical Benefit Authorization Grids are plan specific.
  • If a medication is listed on one of the above authorization grids/tools, an authorization is required prior to use/billing date of service.
  • If a medication is not listed, no prior authorization is needed.
• Physician administered drugs remain in-scope under the Fidelis Care Medical Benefit for Medicaid & HARP members (not impacted by NYS Pharmacy Benefit transition).
• Medical Benefit Pharmacy prior authorizations can be faxed with the “Medical Benefit Request Only” section filled out.
  • If faxing is not an option or not-preferred, submission of a prior authorization electronically via ePA, and/or called in to Fidelis Care directly is also an option.

Additional Tips

• Please ensure Medication PA Requests are submitted utilizing the most current version of the Fidelis Care Medication Request form. This is available on fideliscare.org/pharmacy, under the ‘Utilization Management Programs’ tab.
• Please fully complete the Fidelis Care Medication Request form prior to submission and include any pertinent clinical documentation supporting the medication request with your initial submission.
• Please ensure the J-/Q-code (HCPCS code) requested is the SAME J-/Q-code that a claim is intended to be billed for. Claims payment may be impacted if the J-/Q-code billed is misaligned to the J-/Q-code on an approved Medication PA.
• Please note the ‘MEDICAL BENEFIT REQUESTS ONLY’ section and ensure it is also completed in full prior to submission.  This includes the Servicing Provider information.
• The Servicing Provider is the entity that will submit the claim to Fidelis Care Medical Benefit.
• The absence of a medication from the authorization grid or the obtainment of a prior authorization is not a guarantee for reimbursement as there are other factors to consider when reviewing a claim submission.

Medications Covered Under Fidelis Care Pharmacy Benefit

• Coverage is dictated by Fidelis Care Formularies.
  • Members obtain medications from community or retail outpatient pharmacies.
  • Pharmacy Benefit Formularies are plan specific.
  • Each formulary clearly indicates whether or not a medication requires a prior authorization. 
  • Non-formulary (NF) medications also require authorization prior to the prescription being filled at a community or retail outpatient pharmacy.
  • As of 4/1/2023, Medicaid & HARP Pharmacy benefits are administered by the NYS NYRx program. Visit the NYRx program website for information on the NYRx Preferred Drug List (PDL) and Prior Authorization submission requirements.
• Pharmacy Benefit Pharmacy Prior Authorizations can be faxed, submitted electronically via ePA, and/or called in to Fidelis Care directly.

Additional Tips

• Please ensure Medication PA Requests are submitted utilizing the most current version of the Fidelis Care Medication Request form. This is available on fideliscare.org/pharmacy, under the ‘Utilization Management Programs’ tab.
• Please fully complete the Fidelis Care Medication Request form prior to submission and include any pertinent clinical documentation supporting the medication request with your initial submission.

• Please leave the ‘MEDICAL BENEFIT REQUESTS ONLY’ section BLANK when submitting a request under the pharmacy benefit.

For additional questions, or if we can be of assistance in any way, please contact your Fidelis Care Provider Engagement Account Manager. To find your designated representative, please visit Contact Your Designated Provider Relations Specialist.