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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.

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.

If you have any questions, please contact your Fidelis Care Provider Engagement Account Manager. To find your designated representative, please click here.