Getting your prescriptions filled
Fill your prescription at a network pharmacy
In most cases, the plan will pay for prescriptions only if they are filled at the plan’s network pharmacies. A network pharmacy is a drug store that has agreed to fill prescriptions for our plan members. You may go to any of our network pharmacies.
- To find a network pharmacy, you can look in the Provider and Pharmacy Directory, visit our website, or contact Participant Services or your Care Manager.
Show your plan ID card when you fill a prescription
To fill your prescription, show your plan ID card at your network pharmacy. The network pharmacy will bill the plan for your covered prescription or over-the-counter (OTC) drug.
If you do not have your plan ID card with you when you fill your prescription, ask the pharmacy to call the plan to get the necessary information.
If the pharmacy is not able to get the necessary information, you may have to pay the full cost of the prescription when you pick it up. You can then ask Fidelis Care FIDA Plan to pay you back. If you cannot pay for the drug, contact Participant Services right away. We will do what we can to help.
- To learn how to ask us to pay you back, see Chapter 7 of the FIDA member handbook.
- If you need help getting a prescription filled, you can contact Participant Services or your Care Manager.
What if you want to change to a different network pharmacy?
If you change pharmacies and need a refill of a prescription, you can ask your pharmacy to transfer the prescription to the new pharmacy.
- If you need help changing your network pharmacy, you can contact Participant Services or your Care Manager.
What if the pharmacy you use leaves the network?
If the pharmacy you use leaves the plan’s network, you will have to find a new network pharmacy.
- To find a new network pharmacy, you can look in the Provider and Pharmacy Directory, visit our website, or contact Participant Services or your Care Manager.
What if you need a specialized pharmacy?
Sometimes prescriptions must be filled at a specialized pharmacy. Specialized pharmacies include:
- Pharmacies that supply drugs for home infusion therapy.
- Pharmacies that supply drugs for residents of a long-term care facility, such as a nursing facility. Usually, long-term care facilities have their own pharmacies. Residents may get prescription and OTC drugs through a facility’s pharmacy as long as it is part of our network. If your long-term care facility’s pharmacy is not in our network, please contact your Care Manager or Participant Services.
- Pharmacies that serve the Indian Health Service/Tribal/Urban Indian Health Program. Except in emergencies, only Native Americans or Alaska Natives may use these pharmacies.
- Pharmacies that supply drugs requiring special handling and instructions on their use.
- To find a specialized pharmacy, you can look in the Provider and Pharmacy Directory, visit our website, or contact Participant Services or your Care Manager.
The plan’s Drug List
The plan has a List of Covered Drugs. We call it the “Drug List” for short.
The drugs on the Drug List are selected by the plan with the help of a team of doctors and pharmacists. The Drug List also tells you if there are any rules you need to follow to get your drugs.
We will generally cover a drug on the plan’s Drug List as long as you follow the rules explained in chapter 5 of the FIDA member handbook.
What is on the Drug List?
The Drug List includes the drugs covered under Medicare Part D and some prescription and over-the-counter (OTC) drugs covered under your Medicaid benefits.
The Drug List includes both brand-name and generic drugs. Generic drugs have the same ingredients as brand-name drugs. Generally, they work just as well as brand-name drugs and usually cost less.
Our plan also covers certain over-the-counter drugs. Some over-the-counter drugs cost less than prescription drugs and work just as well. For more information, call Participant Services or your Care Manager.
How can you find out if a drug is on the Drug List?
To find out if a drug you are taking is on the Drug List, you can:
- Check the most recent Drug List we sent you in the mail.
- Visit the plan’s website at www.fideliscare.org. The Drug List on the website is always the most current one.
- Call Participant Services to find out if a drug is on the plan’s Drug List or to ask for a copy of the list.
What is not on the Drug List?
The plan does not cover all prescription drugs or all over-the-counter (OTC) drugs. Some drugs are not on the Drug List because the law does not allow the plan to cover those drugs. In other cases, we have decided not to include a drug on the Drug List.
Fidelis Care FIDA Plan will not pay for the drugs listed in this section. These are called excluded drugs. If you get a prescription for an excluded drug, you must pay for it yourself. If you think we should pay for an excluded drug because of your case, you can file an appeal. (To learn how to file an appeal, see Chapter 9 of the FIDA member handbook.)
Here are three general rules for excluded drugs:
- Our plan’s outpatient drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B. Drugs that would be covered under Medicare Part A or Part B are covered under our plan’s medical benefit.
- Our plan cannot cover a drug purchased outside the United States and its territories.
- The use of the drug must be either approved by the Food and Drug Administration or supported by certain reference books as a treatment for your condition. Your doctor might prescribe a certain drug to treat your condition, even though it was not approved to treat the condition. This is called off-label use. Our plan usually does not cover drugs when they are prescribed for off-label use.
- Fidelis Care does not cover certain family planning and reproductive health services, such as abortion, sterilization, and prescription birth control. New York State requires us to inform you that you can use your Medicaid card to get these services from any doctor or clinic that accepts Medicaid. You do not need a referral from your PCP to get these services.
Also, by law, the types of drugs listed below are not covered by Medicare or Medicaid.
- Drugs used to promote fertility
- Drugs used for cosmetic purposes or to promote hair growth
- Drugs used for the treatment of sexual or erectile dysfunction, such as Viagra®, Cialis®, Levitra®, and Caverject®
- Drugs used for treatment of anorexia, weight loss, or weight gain
- Outpatient drugs when the company who makes the drugs say that you have to have tests or services done only by them
What are tiers?
Every drug on the plan’s Drug List is in one of 2 tiers.
To find out which tier your drug is in, look for the drug in the plan’s Drug List.
Can you use mail-order services to get your drugs?
For certain kinds of drugs, you can use the plan’s network mail-order services. Generally, the drugs available through mail-order are drugs that you take on a regular basis for a chronic or long-term medical condition. The drugs that are not available through the plan’s mail-order service are marked with NM in our Drug List. The drugs available through our plan’s mail-order service are marked as mail-order on our Drug List.
Our plan’s mail-order service allows you to order at least a 30-day supply of the drug and no more than a 90-day.
How do I fill my prescriptions by mail?
To get information about filling your prescriptions by mail, contact Participant Services at 1-800-247-1447 or 1-800-695-8544 (TTY).
Usually, a mail-order prescription will get to you within 10 days. If we anticipate a delay in shipment of more than 10 days, we will contact you within 24 hours of receiving and logging the prescription. We will consult with you to help you decide whether to wait for the medication, cancel the mail order, or fill the prescription at a local pharmacy.
How will the mail-order service process my prescription?
The mail-order service has different procedures for new prescriptions it gets from you, new prescriptions it gets directly from your provider’s office, and refills on your mail-order prescriptions:
1. New prescriptions the pharmacy receives from you
The pharmacy will automatically fill and deliver new prescriptions it receives from you.
2. New prescriptions the pharmacy receives directly from your provider’s office
After the pharmacy receives a prescription from a health care provider, it will contact you to see if you want the medication filled immediately or at a later time. This will give you an opportunity to make sure the pharmacy is delivering the correct drug (including strength, amount, and form) and, if needed, allow you to stop or delay the order before it is shipped. It is important that you respond each time you are contacted by the pharmacy, to let them know what to do with the new prescription and to prevent any delays in shipping.
3. Refills on mail-order prescriptions
For refills, please contact your pharmacy 10 days before you think the drugs you have on hand will run out to make sure your next order is shipped to you in time.
So the pharmacy can reach you to confirm your order before shipping, please make sure to let the pharmacy know the best ways to contact you. Participants can contact Participant Services for more information.
Can you get a long-term supply of drugs?
You can get a long-term supply of maintenance drugs on our plan’s Drug List. Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.
Some network pharmacies allow you to get a long-term supply of maintenance drugs. The Provider and Pharmacy Directory tells you which pharmacies can give you a long-term supply of maintenance drugs. You can also call Participant Services or your Care Manager for more information.
For certain kinds of drugs, you can use the plan’s network mail-order services to get a long-term supply of maintenance drugs. See the section above to learn about mail-order services.
Can you use a pharmacy that is not in the plan’s network?
Generally, we pay for drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy.
We will pay for prescriptions filled at an out-of-network pharmacy in the following cases:
- If you are unable to get a covered drug in a timely manner within our service area because there are no in-network pharmacies within a reasonable distance from your residence.
- If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail-order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals).
- If the drug is related to care for a medical emergency or urgently needed care.
- In these cases, please check first with Participant Services to see if there is a network pharmacy nearby.
Will the plan pay you back if you pay for a prescription at a pharmacy not in the plan’s network?
Sometimes a pharmacy that is not in the plan’s network will require you to pay the full cost for the drug and seek payment from us. You can ask Fidelis Care FIDA Plan to pay you back.
Why do some drugs have limits?
For certain prescription and covered over-the-counter (OTC) drugs, special rules limit how and when the plan covers them. In general, our rules encourage you to get a drug that works for your medical condition and is safe and effective. When a safe, lower-cost drug will work just as well as a higher-cost drug, the plans expects your provider to prescribe the lower-cost drug.
If there is a special rule for your drug, it usually means that the prescribing provider will have to give us or your Interdisciplinary Team (IDT) extra information, or you or your provider will have to take extra steps for us to cover the drug. For example, your provider may have to tell us your diagnosis or provide results of blood tests first. If you or your provider thinks the rule should not apply to your situation, you should ask Fidelis Care FIDA Plan or your IDT to make an exception. Fidelis Care FIDA Plan or your IDT may or may not agree to let you use the drug without taking the extra steps.
- To learn more about asking for exceptions, see Chapter 9 of the FIDA member handbook.
What kinds of rules are there?
1. Limiting use of a brand-name drug when a generic version is available
Generally, a generic drug works the same as a brand-name drug and usually costs less. In most cases, if there is a generic version of a brand-name drug, our network pharmacies will give you the generic version. We usually will not pay for the brand-name drug when there is a generic version. However, if your provider has told us or your IDT the medical reason that the generic drug and other covered drugs that treat the same condition will not work for you and has written “DAW” (Dispense as Written) on your prescription for a brand-name drug, then Fidelis Care FIDA Plan or your IDT will approve the brand-name drug.
2. Getting plan or IDT approval in advance
For some drugs, you or your doctor must get approval from the plan or your IDT before you fill your prescription. If you don’t get approval, we may not cover the drug. Your IDT may approve drugs as part of your Person-Centered Service Plan (PSCP), or you can ask Fidelis Care FIDA Plan for approval.
See the list of medications that require prior authorization:
During the first 90 days of your membership in the plan, you do not need the plan or your IDT to approve a refill request for an existing prescription, even if the drug is not on our Drug List or is limited in some way. See section D for more information about getting a temporary supply.
You do not need the plan or the IDT to approve in advance drugs that are on our Drug List. For drugs that are not on our Drug List but where a refill request is made for an existing prescription during the first 90 days of your membership in the plan, you do not need the plan or the IDT to approve these drugs in advance. IDT approval is not required for drugs, but your IDT may authorize drugs as part of your Person-Centered Service Plan (PSCP). At a minimum, your IDT will discuss and incorporate a list of drugs you are using in your PSCP.
3. Trying a different drug first
In general, the plan wants you to try lower-cost drugs (that often are as effective) before the plan covers drugs that cost more. For example, if Drug A and Drug B treat the same medical condition, and Drug A costs less than Drug B, Fidelis Care FIDA Plan’s rules may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. This is called step therapy.
See the criteria for medications in our step therapy program:
4. Quantity limits
For some drugs, we limit the amount of the drug you can have. For example, the plan
- how many refills you can get, or
- how much of a drug you can get each time you fill your prescription.
Do any of these rules apply to your drugs?
To find out if any of the rules above apply to a drug you take or want to take, check the
Drug List. For the most up-to-date information, call Participant Services or check our website at www.fideliscare.org/fida.
Why your drug might not be covered
We try to make your drug coverage work well for you, but sometimes a drug might not be covered in the way that you would like it to be. For example:
- The drug you want to take is not covered by the plan. The drug might not be on the Drug List. A generic version of the drug might be covered, but the brand name version you want to take is not. A drug might be new and we have not yet reviewed it for safety and effectiveness.
- The drug is covered, but there are special rules or limits on coverage for that drug. As explained in the section above, some of the drugs covered by the plan have rules that limit their use. In some cases, you or your prescriber may want to ask Fidelis Care FIDA Plan or your Interdisciplinary Team (IDT) for an exception to a rule.
There are things you can do if your drug is not covered in the way that you would like it to be.
You can get a temporary supply
In some cases, the plan can give you a temporary supply of a drug when the drug is not on the Drug List or when it is limited in some way. This gives you time to talk with your provider about getting a different drug or to ask Fidelis Care FIDA Plan or your IDT to approve the drug.
To get a temporary supply of a drug, you must meet the two rules below:
1. The drug you have been taking:
- is no longer on the plan’s Drug List, or
- was never on the plan’s Drug List, or
- is now limited in some way.
2. You must be in one of these situations:
- You are new to the plan and do not live in a long-term care facility.
We will cover a temporary supply (or supplies) of your drug during the first 90 days of your membership in the plan. This temporary supply will be for up 90 days. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 90 days of medication. You must fill the prescription at a network pharmacy.
- You are new to the plan and live in a long-term care facility.
We will cover a temporary supply (or supplies) of your drug during the first 90 days of your membership in the plan. The total supply will be for 91 days. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 98 days of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
- You have been in the plan for more 90 days and live in a long-term care facility and need a supply right away.
We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
- Level of Care Transition Fills are allowed up to a 31-day supply except for oral brand solids which are limited to 14-day fills with exceptions as required by CMS guidance, unless submitted with an override by the network pharmacy.
To ask for a temporary supply of a drug, call Participant Services.
When you get a temporary supply of a drug, you should talk with your provider to decide what to do when your supply runs out. Here are your choices:
- You can change to another drug.
There may be a different drug covered by the plan that works for you. You can call Participant Services to ask for a list of covered drugs that treat the same medical condition. The list can help your provider find a covered drug that might work for you.
- You can ask for an exception.
You and your provider can ask Fidelis Care FIDA Plan or your IDT to make an exception. For example, you can ask Fidelis Care FIDA Plan or your IDT to approve a drug even though it is not on the Drug List. Or you can ask Fidelis Care FIDA Plan or your IDT to approve and cover the drug without limits. If your provider says you have a good medical reason for an exception, he or she can help you ask for one.
If a drug you are taking will be taken off the Drug List or limited in some way for next year, we will allow you to ask for an exception. We will tell you about any change in the coverage for your drug for next year. You can then ask us or your IDT to make an exception and cover the drug in the way you would like it to be covered for next year. Fidelis Care FIDA Plan or your IDT will answer your request for an exception within 72 hours after we receive your request (or your prescriber’s supporting statement).
- To learn more about asking for an exception, see Chapter 9 of the FIDA member handbook.
- If you need help asking for an exception, you can contact Participant Services or your Care Manager.
Changes in coverage for your drugs
Most changes in drug coverage happen on January 1. However, the plan might make changes to the Drug List during the year. The plan might:
- Add drugs because new drugs, including generic drugs, became available or the government approved a new use for an existing drug.
- Remove drugs because they were recalled or because cheaper drugs work just as well.
- Add or remove a limit on coverage for a drug.
- Replace a brand-name drug with a generic drug.
If any of the changes below affect a drug you are taking, the change will not affect you until January 1 of the next year:
- We put a new limit on your use of the drug.
- We remove your drug from the Drug List, but not because of a recall or because a new generic drug has replaced it.
Before January 1 of the next year, you usually will not have an increase in your payments or added limits to your use of the drug. The changes will affect you on January 1 of the next year.
In the following cases, you will be affected by the coverage change before January 1:
- If a brand name drug you are taking is replaced by a new generic drug, the plan must give you at least 60 days’ notice about the change.
- The plan may give you a 60-day refill of your brand-name drug at a network pharmacy.
- You should work with your Care Manager or your provider during those 60 days to change to the generic drug or to a different drug that the plan covers.
- You and your Care Manager or your provider can ask the plan to continue covering the brand-name drug for you. To learn how, see Chapter 9 of the FIDA member handbook.
- If a drug is recalled because it is found to be unsafe or for other reasons, the plan will remove the drug from the Drug List. We will tell you about this change right away.
- Your Care Manager and your provider will also know about this change. He or she can work with you to find another drug for your condition.
- If there is a change to coverage for a drug you are taking, the plan will send you a notice. Normally, the plan will let you know at least 60 days before the change.
Drug coverage in special cases
If you are in a long-term care facility
Usually, a long-term care facility, such as a nursing facility, has its own pharmacy or a pharmacy that supplies drugs for all of its residents. If you are living in a long-term care facility, you may get your prescription drugs through the facility’s pharmacy if it is part of our network.
Check your Provider and Pharmacy Directory to find out if your long-term care facility’s pharmacy is part of our network. If it is not, or if you need more information, please contact your Care Manager or Participant Services.
If you are in a long-term care facility and become a new member of the plan
If you need a drug that is not on our Drug List or is restricted in some way, the plan will cover a temporary supply or multiple temporary supplies up 91 days when you request a refill during the 90 days of your membership.
If you have been a member of the plan for more than 90 days and you need a drug that is not on our Drug List, we will cover one 31-day supply. We will also cover 31-day supply if the plan has a limit on the drug’s coverage. If your prescription is written for fewer than 31 days, we will pay for the smaller amount.
When you get a temporary supply of a drug, you should talk with your Care Manager or your provider to decide what to do when your supply runs out. A different drug covered by the plan might work just as well for you. Or you and your Care Manager or your provider can ask the plan to make an exception and cover the drug in the way you would like it to be covered.
- To learn more about asking for exceptions, see Chapter 9 of the FIDA member handbook.
If you are in a Medicare-certified hospice program
Drugs are never covered by both hospice and our plan at the same time. If you are enrolled in a Medicare hospice and require a pain medication, anti-nausea, laxative, or antianxiety drug not covered by your hospice because it is unrelated to your terminal illness and related conditions, our plan must receive notification from either the prescriber or your hospice provider that the drug is unrelated before our plan can cover the drug. To prevent delays in receiving any unrelated drugs that should be covered by our plan, you can ask your hospice provider or prescriber to make sure we have the notification that the drug is unrelated before you ask a pharmacy to fill your prescription.
If you leave hospice, our plan should cover all of your drugs. To prevent any delays at a pharmacy when your Medicare hospice benefit ends, you should bring documentation to the pharmacy to verify that you have left hospice. See the previous parts of chapter 5 of the FIDA member handbook that tell about the rules for getting drug coverage under Part D.
- To learn more about the hospice benefit, see Chapter 4 of the FIDA member handbook.
Programs on drug safety and managing drugs
Programs to help Participants use drugs safely
Each time you fill a prescription, we look for possible problems, such as:
- Drug errors
- Drugs that may not be needed because you are taking another drug that does the same thing
- Drugs that may not be safe for your age or gender
- Drugs that could harm you if you take them at the same time
- Drugs that are made of things you are allergic to
If we see a possible problem in your use of prescription drugs, we will notify your Care Manager and have your Interdisciplinary Team (IDT) work with your provider to correct the problem.
Programs to help Participants manage their drugs
If you take medications for different medical conditions, you may be eligible to get services, at no cost to you, through a medication therapy management (MTM) program. This program helps you and your provider make sure that your medications are working to improve your health. A pharmacist or other health professional will give you a comprehensive review of all your medications and talk with you about:
- How to get the most benefit from the drugs you take
- Any concerns you have, like medication costs and drug reactions
- How best to take your medications
- Any questions or problems you have about your prescription and over‑the‑counter medication
You’ll get a written summary of this discussion. The summary has a medication action plan that recommends what you can do to make the best use of your medications. You’ll also get a personal medication list that will include all the medications you’re taking and why you take them.
It’s a good idea to schedule your medication review before your yearly “Wellness” visit, so you can talk to your doctor about your action plan and medication list. Bring your action plan and medication list with you to your visit or anytime you talk with your doctors, pharmacists, and other health care providers. Also, take your medication list with you if you go to the hospital or emergency room.
Medication therapy management programs are voluntary and free to Participants that qualify. If we have a program that fits your needs, your Interdisciplinary Team (IDT) will discuss whether you should enroll in the program.
- If you have any questions about these programs, please contact Participant Services or your Care Manager.
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 for more information or to register (by clicking on this link, you will leave the Fidelis Care website).
Request for Prescription Drug Coverage Determination
A medication request form must be completed and submitted when your physician is requesting an exception to our Formulary.
Request for Coverage Redetermination of Prescription Drug Denials
If Fidelis Care FIDA Plan 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:
Fidelis Care FIDA Plan
97-77 Queens Boulevard - 12th Floor
Rego Park, New York 11374
Participants may ask us for a Prescription Drug Redetermination (appeal) through our website by clicking the link below:
Expedited appeal requests can be made by phone at 1-800-247-1447 (TTY: 1-800-695-8544). From October 1 to February 14, our office hours are 8:00 a.m. to 8:00 p.m. seven days a week and from February 15 through September 30, our office hours are Monday through Friday, 8:00 a.m. to 8:00 p.m.
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. Contact us to learn how to name a representative.
(Updated 9/28/2016) H1916_FC FIDA 16011 Pending