Prescription Drug Information

Medicare "Part D" Prescription Drug Formulary


A drug formulary is a list of both generic and brand name prescription drugs that are covered by your prescription drug benefit. The formulary is actively managed and updated through Wellcare By Fidelis Care's Pharmacy and Therapeutics Committee, qualified pharmacists and doctors whose primary focus is offering safe, high-quality and cost-effective drugs. New drugs are added to the formulary periodically based on the latest medical research and some drugs may be removed periodically based on the findings and recommendations of the Pharmacy and Therapeutics Committee.

 Learn about Medication Therapy Management

Cost-Savings Options

You may be able to spend less each month on your prescription drugs. Here are three ways to save:

  1. If you're not taking a preferred drug, talk to your provider about switching to one that’s on our Formulary. Your doctor can reference the formulary when recommending prescription drugs as part of your health care plan.
  2. If you’re on any brand name drugs, switching to generic when available will likely reduce your out-of-pocket costs. Check our Formulary, or use our Formulary Search tool to find generic alternatives. 
  3. Switch to 90-day mail order fill. One 90-day supply often costs less than three 30-day supplies at a retail pharmacy. Plus, home delivery is at no extra cost!   Learn about our Mail Order Pharmacy Program

Prescription Drug Benefits

Click below for formulary, prior authorization, step therapy criteria, mail order enrollment, and other Medicare Part D prescription drug benefits provided by Wellcare By Fidelis Care's Medicare and Dual Advantage plans.

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Prescription Drug Formularies

Formularies

2023

2023 Comprehensive Formulary | Wellcare Fidelis Assist (Plan 002) 

2023 Comprehensive Formulary | Wellcare Fidelis No Premium (Plan 004) 

2023 Comprehensive Formulary | Wellcare Fidelis Dual Access & Dual Plus (Plans 001, 003, 008) 

Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you, even if you haven’t paid your deductible*. Call Member Services for more information.

Important Message About What You Pay for Insulin - You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t paid your deductible*.


Additional Documents
  •  2023 Formulary Transition Policy
  •  2023 Covered Diabetes Meters and Testing Supplies
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    2022

    2022 Comprehensive Formulary

    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 Wellcare By 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.



      Formulary Transition Policy
      When you have a drug that is not on our formulary, or if your ability to get the drug is limited, we will cover a temporary supply of the drug until you can switch to a drug we cover or you can request a formulary exception.

       

    • 2022 Formulary Transition Policy
    • 2022 Covered Diabetes Meters and Testing Supplies
    • Prior Authorization

      Prior Authorization (PA) Criteria

      2023

      2023 PA Criteria | Wellcare Fidelis Assist (Plan 002) 

      2023 PA Criteria | Wellcare Fidelis No Premium (Plan 004) 

      2023 PA Criteria | Wellcare Fidelis Dual Access & Dual Plus (Plans 001, 003, 008) 


      2022

      2022 PA Criteria


      Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. If your drug needs this step, you or your doctor will need to ask for and get advance approval from Wellcare By Fidelis Care to cover the drug. 

      Step Therapy

      Step Therapy (ST) Criteria

      2023

      2023 ST Criteria | Wellcare Fidelis Assist (Plan 002) 

      2023 ST Criteria | Wellcare Fidelis No Premium (Plan 004) 

      2023 ST Criteria | Wellcare Fidelis Dual Access & Dual Plus (Plans 001, 003, 008) 



      2022

      2022 ST Criteria 


      Step Therapy is a process whereby prescriptions are filled using an effective and more affordable medication (Step 1). When appropriate, a more costly (Step 2) medication can be authorized if the Step 1 prescription is found to not be effective in treating your medical condition.  

      Pharmacy Network
      Pharmacy Network

      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.

      Visit the CVS Caremark website (by clicking on this link, you will leave the Fidelis Care website) for more information or to register. 

      Requesting/Appealing Coverage Determinations

      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


      Request for Coverage Redetermination of Prescription Drug Denials
      If Fidelis Medicare Advantage denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Prescription Drug Coverage to ask us for a redetermination. This form may be sent to us by mail or fax:

      Address:

      Wellcare By Fidelis Care
      Attention: Pharmacy Services Department
      PO Box 9525 
      Amherst, NY 14226


      Fax Number: 
      1-877-882-5892

      Members  may ask us for an appeal through our website at www.fideliscare.org. Expedited appeal requests can be made by phone at 1-800-247-1447. Your prescribing doctor  may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. 

      Extra Help With Drug Costs and Best Available Evidence

      Medicare Extra Help Program for Prescription Drug Costs

      2022/2023 Benefit Parameters Chart

       


      PDF Downloads: 

      Wellcare By Fidelis Care's premium includes coverage for both medical services and prescription drug coverage.

      If you aren't getting extra help, you can see if you qualify by calling:

      • 1-800-MEDICARE (1-800-633-4227); TTY users call 1-877-486-2048  (24 hours a day/7 days a week)
      • Your State Medicaid Office, or
      • The Social Security Administration at 1-800-772-1213. TTY users should call 1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.
      Mail Order Prescription Drugs

      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 two 30-day supplies picked up at the pharmacy counter.

      Mail Order Durable Medical Equipment

      For your convenience, Wellcare By 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

       

      Medication not Covered?

      Click HERE to request coverage for 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.
        *Approval is not guaranteed.

      CVS Caremark

      Wellcare By Fidelis Care is committed to making sure you have access to affordable medication and convenient options for filling prescriptions. Our pharmacy partner, CVS Caremark, offers tools that make managing your prescriptions easier. (By clicking this link, you will leave the Fidelis Care website.) 

       

      Apply for 'Extra Help' Benefit

      Did you get Extra Help - Low Income Subsidy Assistance - paying for your prescription drug costs in 2022?  To get assistance again this year, you must apply for recertification.  View or download our Prescription Drug Extra Help Checklist to ease your qualification process.

      OTC Benefit

      Wellcare By Fidelis Care offers members a prepaid account that is replenished monthly or quarterly, depending on your plan. You can use this account to purchase non-prescription, over-the-counter drugs and many common health-related items at local pharmacies.

       

       

      Additional Information

      Wellcare is the Medicare brand for Centene Corporation, an HMO, PPO, PFFS, PDP plan with a Medicare contract and is an approved Part D Sponsor. Our D-SNP plans have a contract with the state Medicaid program. Enrollment in our plans depends on contract renewal.

      From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends and on federal holidays.

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      Last Updated 11.20.2022