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Fidelis Care Pharmacy Benefits and Authorizations
8/28/2024 • Posted by Provider Relations

Fidelis Care’s Pharmacy Services would like to provide 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 Engagement Account Manager. To find your designated representative, please click here

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