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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

Medications that are administered to a member during an outpatient visit are covered under the member’s medical benefit.  The authorization requests and claims for these medications should be processed through Fidelis Care using the guidelines and tips below, for all Lines of Business.

• Physician Administered Drugs – medications administered to a member during 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/tools, an authorization is required prior to use/billing date of service.
  • If a medication is not listed, no prior authorization is needed to receive paid claims.
• 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.

Additional Tips

• Please ensure Medication PA Requests are submitted utilizing the most current version of the Fidelis Care Medication Request form. This is available on fideliscare.org/pharmacy, under the ‘Utilization Management Programs’ tab.
• Please fully complete the Fidelis Care Medication Request form prior to submission and include any pertinent clinical documentation supporting the medication request with your initial submission.
• Please ensure the J-/Q-code (HCPCS code) requested is the SAME J-/Q-code that a claim is intended to be billed for. Claims payment may be impacted if the J-/Q-code billed is misaligned to the J-/Q-code on an approved Medication PA.
• Please note the ‘MEDICAL BENEFIT REQUESTS ONLY’ section and ensure it is also completed in full prior to submission.  This includes the Servicing Provider information.
• The Servicing Provider will submit the claim to Fidelis Care Medical Benefit for the requested medication if the request is approved, such as the request providers’ office (‘Buy and Bill’ OR a Specialty Pharmacy (‘Drop shipment’).

Medications Covered Under Fidelis Care Pharmacy Benefit

Medications that are self-administered by the member are covered under the member’s pharmacy benefit. 

• 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.
• For all other Lines of Business, the authorization requests and claims for these medications should be processed through Fidelis Care using the guidelines and tips below.

• 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 whether or not a medication requires a prior authorization. 
  • Non-formulary (NF) medications also require authorization prior to the prescription being filled at a community or retail outpatient pharmacy.
• Pharmacy Benefit Pharmacy Prior Authorizations can be faxed, submitted electronically via ePA, and/or called in to Fidelis Care directly.

Additional Tips

• Please ensure Medication PA Requests are submitted utilizing the most current version of the Fidelis Care Medication Request form. This is available on fideliscare.org/pharmacy, under the ‘Utilization Management Programs’ tab.
• Please fully complete the Fidelis Care Medication Request form prior to submission and include any pertinent clinical documentation supporting the medication request with your initial submission.

Please note: For some medications, it is possible that the medication is FDA-approved for both above administration types. In these scenarios, the provider will need to follow the path outlined based on their treatment plan for the specific member.

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