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Pharmacy Services

Express Scripts

Fidelis Care is pleased to announce that, effective January 1, 2024, Express Scripts® began processing pharmacy claims for our plan members.

Providers can direct members to call the Member Services phone number listed on their ID card should they have questions about this change. Alternatively, Fidelis Care has created an Express Scripts FAQ for providers to reference in order to assist members. The FAQ also includes information on mail order services for members that are currently using this method of delivery.

Please note that Acaria remains in network under Express Scripts as an option for your members Specialty Medication needs.

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

 

NYRx

Effective April 1, 2023, members enrolled in Fidelis Care Medicaid Managed Care and HealthierLife (HARP) plans will receive their pharmacy benefits through NYRx, the Medicaid Fee-for-Service (FFS) Pharmacy Program. For more information regarding the pharmacy benefit transition, please visit NYRx, the Medicaid Pharmacy Program. Please note, members will continue to receive their medical benefits through Fidelis Care.

Certain durable medical equipment such as nebulizers, wheelchairs, hospital beds, etc are available under the Fidelis Care medical benefit for these members. For a complete list of covered items, please refer to section 4.4, 4.5, 4.6, and 4.7 in The New York DMEPOS Manual. Please use the Find-A-Doc Tool to locate a Durable Medical Equipment supplier. 


Drug Shortage Information

Please refer to the FDA website for the most current and full list of drug shortages. Please refer to the plan-specific formulary for a full comprehensive list of potential alternatives. For NYM/HARP Plans, please refer to the State's Preferred Drug List.


Click the categories below for important pharmacy documents and resources. 

Utilization Management Programs

Opioid Prior Authorization Form (PDF)  Effective April 1, 2023, members enrolled in Fidelis Care Medicaid Managed Care and HealthierLife (HARP) plans will receive their pharmacy benefits through NYRx, the Medicaid Fee-for-Service (FFS) Pharmacy Program. To initiate a Prior Authorization, please use the following form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf

Medication Request Form for Medicaid, HARP, CHP, Essential Plans, and Qualified Health Plans (PDF)

Pharmacy Electronic Prior Authorizations Effective April 1, 2023, members enrolled in Fidelis Care Medicaid Managed Care and HealthierLife (HARP) plans will receive their pharmacy benefits through NYRx, the Medicaid Fee-for-Service (FFS) Pharmacy Program. To initiate a Prior Authorization, please use the following form: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf


Wellcare By Fidelis Care

Medicare Medication Request Form (PDF)

Medicare Prescription Drug Denial Request for Redetermination (PDF)

Medicare Electronic Drug Coverage Determination Form (Web Resource)

Medicare Prescription Drug Denial Request for Redetermination Online Form (Web Resource)

Medicare Medication Request Form - Medical Benefit (Medicare Part B) (PDF)  [This form is to be completed for Wellcare By Fidelis Care Medicare members (including Dual members) for medications to be supplied from the practitioner and/or office stock supply and billed as part of a practitioner service.]

Evolent Oncology Program (formerly New Century Health)

Oncology Services - Medicaid Managed Care and HealthierLife


Oncology Services - Essential Plan and Metal-Level Products (QHP)


Oncology Services - Medicare | Wellcare by Fidelis Care

Formularies

HealthierLife (HARP) and Medicaid Managed Care (MMC)

Effective April 1, 2023, members enrolled in Fidelis Care Medicaid Managed Care and HealthierLife (HARP) plans will receive their pharmacy benefits through NYRx, the Medicaid Fee-for-Service (FFS) Pharmacy Program.


Qualified Health Plans (Metal-Level Products)


    Child Health Plus (CHP) 


    Essential Plan (EP)


    Wellcare By Fidelis Care Medicare and Dual Advantage Plans

    Formularies

    2025

    2025 Comprehensive Formulary | Wellcare Fidelis Dual Access (Plan 001)

    2025 Comprehensive Formulary | Wellcare Fidelis Assist (Plan 002)

    2025 Comprehensive Formulary | Wellcare Fidelis Dual Plus (Plan 003)

    2025 Comprehensive Formulary | Wellcare Fidelis Simple (Plan 004)


    2024

    2024 Comprehensive Formulary | Wellcare Fidelis Assist (Plan 002) 

    2024 Comprehensive Formulary | Wellcare Fidelis No Premium (Plan 004) 

    2024 Comprehensive Formulary | Wellcare Fidelis Dual Access & Dual Plus (Plans 001, 003, 008) 

     

    Prior Authorization (PA) Criteria

    2025


    2024


    Step Therapy (ST) Criteria

    2025


    2024


    Additional Plan Documents

    2025

  • 2025 Covered Diabetes Meters and Testing Supplies
  • 2025 Formulary Transition Policy

  • 2024

  • 2024 Covered Diabetes Meters and Testing Supplies
  • 2024 Formulary Transition Policy 

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    Provider Access Online

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    Manuals and Forms

    Provider manuals, tip sheets, important forms, and applications. 

    Authorization Grids

    Authorization Grids for Medicare, Medicaid, CHP, and NYSOH Marketplace.