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Fidelis Care would like to inform providers of recent updates to the Fidelis Care Medication Request Form, that is used for requesting Medication Prior Authorizations under either the Medical or Pharmacy Benefit.

The updated Fidelis Care Medication Request Form is available on www.fideliscare.org/pharmacy, in the Utilization Management Programs section (labeled Medication Request Form for Medicaid, HARP, CHP, Essential Plans, and Qualified Health Plans).

Please ensure your practice has the updated Fidelis Care Medication Request Form on file, and uses it for any future Medical Benefit or Pharmacy Benefit Medication Prior Authorization submissions to Fidelis Care.

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. Thank you for being a valued Fidelis Care partner in the provision of quality care.