2024/8/28
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Posted by Provider Relations
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Provider News
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.
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Line of Business
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Medical Benefit Initial Request Fax Number
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Medical Benefit Appeals Request Fax Number
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Medicare
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844-235-5090
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833-757-0611 (only for Part B)
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Medicaid, CHP, EP, & Ambetter
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844-235-5090
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844-235-5091
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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.
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Line of Business
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Pharmacy Benefit Initial Request Fax Number
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Pharmacy Benefit Appeals Request Fax Number
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Medicare
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844-235-5021
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866-388-1766
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CHP, EP, & Ambetter
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844-235-4852
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888-865-6531
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If you have any questions, please contact your Fidelis Care Provider Engagement Account Manager. To find your designated representative, please click here.