Medicare Advantage and Dual Advantage

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 managed by our Pharmacy and Therapeutics Committee, qualified pharmacists and doctors who’s 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.

Fidelis Prescription Drug Formulary for 2017 (Managed by CVS Caremark)

Please note that for 2017 we have different formularies depending on which Medicare Advantage or Dual Advantage Plan you are enrolled in. Please make sure to click on the formulary link that is below the plan you are enrolled in. 

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

2017 (English .pdf)
2017 (Español .pdf)

Additional drug list for Fidelis Dual Advantage and Fidelis Medicaid Advantage Plus (.pdf)

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

2017 (English .pdf)
2017 (Español .pdf)

    • 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.

    Part B Diabetic Supplies (.pdf)

    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. 

    Mail Order Prescription Drugs
    Using our mail order program (.pdf), 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.

    You’ll receive these benefits: 

    •  Cost savings - One 90-day supply may cost less than two 30-day supplies at a retail pharmacy
    •  Greater convenience - At-home delivery at no extra cost, and easy refills online or by phone
    •  Quality and safety - Dedicated pharmacists checking each and every order
    •  Added value - 24/7 access to pharmacists, and alert messages by e-mail, text, or phone
    Click here for the Mail Order Enrollment Form (.pdf)

    Mail Order Durable Medical Equipment
    For your convenience, 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

    Mail Order Orthotics and Prosthetics
    Integra Partners can work to get your orthotic or prosthetic devices delivered right to your home.  

    Fax your prescription, insurance information, address, telephone number, date of birth, and any necessary supporting documentation from your doctor to 718-287-1229 with the subject line, “ATTENTION: NEW ORDER.” 

    Upon receipt, Integra’s customer service team will select the best in-network provider to fill your order. Members can check on the status of their order by calling 718-369-0012.

    For more information, visit http://accessintegra.com (clicking this link will cause you to leave the Fidelis Care website)

    Prior Authorization
    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 Fidelis Care to cover the drug. 

    2017
    Fidelis Dual Advantage, Fidelis Medicaid Advantage Plus and Fidelis Dual Advantage Flex 

    Click here to see a list of medications that require prior authorization (.pdf)

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

    Click here to see a list of medications that require prior authorization (.pdf)

    Step Therapy

    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. 

    2017
    Fidelis Dual Advantage, Fidelis Medicaid Advantage Plus and Fidelis Dual Advantage Flex 

    Click here to see the criteria for medications in our step therapy program (.pdf)

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

    Click here to see the criteria for medications in our step therapy program (.pdf)

    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 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.


    LIS Premium Chart

    Click here to view monthly program premiums for people who get extra help from Medicare to help pay for their prescription drug costs

    ​2017

    Formulary Transition Process 

    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.

    2017

    Click here to review our formulary transition policy (.pdf)

    Request for Medicare Prescription Drug Coverage Determination
    A medication request form must be completed and submitted when your physician is requesting an exception to our Medicare Part D Formulary. 

    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:
    Fidelis Medicare Advantage
    97-77 Queens Boulevard - 12th Floor
    Rego Park, New York 11374 

    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. Contact us to learn how to name a representative.

     

     

    Questions? Call our Member Services Department 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.

    Fidelis Care is an HMO plan with a Medicare contract. Enrollment in Fidelis Care depends on contract renewal.

    Fidelis Care is a Coordinated Care plan with a Medicare contract and a contract with the New York State Department of Health Medicaid program. Enrollment in Fidelis Care depends on contract renewal.

    (Updated 10/12/2016) H3328_FC 16153 Approved