4/3/2024
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Posted by Provider Relations
Fidelis Care’s Pharmacy Services would like to provide further 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 the course of 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, a prior authorization is required prior to use/billing date of service in order to receive payment.
- If a medication is not listed, no prior authorization 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, submitted electronically via ePA, and/or called in to Fidelis Care directly.
| Line of Business | Medical Benefit Initial Request Fax Number | Medical Benefit Appeals Request Fax Number |
| Medicare | 844-235-5090 | 833-757-0611 (only for Part B) |
| Medicaid, CHP, EP, & Ambetter | 844-235-5090 | 844-235-5091 |
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 if a medication requires a prior authorization or not. 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.
| Line of Business | Pharmacy Benefit Initial Request Fax Number | Pharmacy Benefit Appeals Request Fax Number |
| Medicare | 844-235-5021 | 866-388-1766 |
| CHP, EP, & Ambetter | 844-235-4852 | 888-865-6531 |
If you have any questions, please contact your Fidelis Care Provider Relations Specialist. To find your designated representative, please click here.