Medicare Advantage and Dual Advantage

Fidelis Legacy Plan

Prescription Drug Information

Medicare "Part D" Prescription Drug Formulary

A drug formulary is a list of both generic and brand name prescription drugs that are covered by your prescription drug benefit. The formulary is managed by our Pharmacy and Therapeutics Committee, qualified pharmacists and doctors whose primary focus is offering safe, high-quality and cost-effective drugs. New drugs are added to the formulary periodically based on the latest medical research and some drugs may be removed periodically based on the findings and recommendations of the Pharmacy and Therapeutics Committee.

Learn about our Mail Order Pharmacy Program

Learn about Medication Therapy Management

Prescription Drug Benefits

Click below for formularies and other Medicare Part D prescription drug benefits provided by Fidelis Care's Medicare Advantage and Dual Advantage plans.

Prescription Drug Formularies

Fidelis Dual Advantage, Fidelis Medicaid Advantage Plus, Fidelis Dual Advantage Flex, Fidelis Medicare Advantage Flex (HMO POS), and Fidelis Medicare $0 Premium (HMO)

2020 Formulary (PDF)

Formulario 2020 (PDF)

Фармакологический справочник на 2020 г. (PDF)

2020年處方一覽表 (PDF)

    • If a drug is not covered in the way you would like it to be covered, you can ask us to make an “exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision. Asking for coverage of a drug that is not on the Prescription Drug Formulary, also called the Drug List, is sometimes called asking for a “formulary exception.” When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. The information can be submitted by phone, fax, mail or electronically. We will then consider your request.

    Part B Diabetic Supplies (PDF)

    Drug Tiers

    The price of a drug is determined by what “tier” it is on within your formulary. A generic drug may appear on a “preferred tier,” while a brand-name drug may appear on a “non-preferred tier.” Medicine listed on a non-preferred tier may be more expensive than those on a preferred tier. You can reduce how much you pay for prescription drugs by using preferred tier drug. You should talk to your primary care physician about preferred tier options available to you.

    Generic Substitution
    If Fidelis Care receives a prior authorization or exception request, the medication requested will be generically substituted when an authorized, AB rated equivalent generic is available, unless the request specifically indicates that the brand name is being requested (e.g. Dispense as Written, brand only, etc.), rejections in prescription claims history are for brand, or supporting documentation indicates brand is being prescribed or why generic is not an appropriate treatment option.

    Prior Authorization

    Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. If your drug needs this step, you or your doctor will need to ask for and get advance approval from Fidelis Care to cover the drug. 

    Fidelis Dual Advantage, Fidelis Medicaid Advantage Plus and Fidelis Dual Advantage Flex Medications Requiring Prior Authorization (PDF)

    Fidelis Medicare Advantage Flex (HMO POS) and Fidelis Medicare $0 Premium (HMO) Medications Requiring Prior Authorization (PDF)

    Prior Authorization Request Form (PDF)

    Step Therapy
    Step Therapy is a process whereby prescriptions are filled using an effective and more affordable medication (Step 1). When appropriate, a more costly (Step 2) medication can be authorized if the Step 1 prescription is found to not be effective in treating your medical condition. 


    Fidelis Dual Advantage, Fidelis Medicaid Advantage Plus and Fidelis Dual Advantage Flex Step Therapy Program Medication Criteria (PDF)

    Fidelis Medicare Advantage Flex (HMO POS) and Fidelis Medicare $0 Premium (HMO) Step Therapy Program Medication Criteria (PDF)

    Formulary Transition Process

    When you have a drug that is not on our formulary, or if your ability to get the drug is limited, we will cover a temporary supply of the drug until you can switch to a drug we cover or you can request a formulary exception.

    Formulary Transition Policy (PDF)

    Pharmacy Network
    Pharmacy Network

    Fidelis Care has contacts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area. There are over 4,400 pharmacies located in New York State that participate in our pharmacy network and over 64,400 network pharmacies nationwide.

    Visit the CVS Caremark website (by clicking on this link, you will leave the Fidelis Care website) for more information or to register. 

    Requesting/Appealing Coverage Determinations

    Request for Medicare Prescription Drug Coverage Determination

    A medication request form must be completed and submitted when your physician is requesting an exception to our Medicare Part D Formulary. 

    Medication Request Form (PDF)

    Request a Prescription Drug Coverage Determination Online

      Request for Coverage Redetermination of Prescription Drug Denials
      If Fidelis Medicare Advantage denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Prescription Drug Coverage to ask us for a redetermination. This form may be sent to us by mail or fax:


      Fidelis Medicare Advantage 

      59-17 Junction Boulevard – 5th Floor 

      Elmhurst, New York 11373

      Fax Number: 

      Members  may ask us for an appeal through our website at Expedited appeal requests can be made by phone at 1-800-247-1447. Your prescribing doctor  may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. 

      Extra Help With Drug Costs and Best Available Evidence

      2020 LIS Premium Chart (PDF)

      This chart shows monthly program premiums for people who get extra help from Medicare to pay for their prescription drug costs. 

      Best Available Evidence

      The Centers for Medicare and Medicaid Services (CMS) created the Best Available Evidence (BAE) policy in 2006 for Part D plans that administer the Low-Income Subsidy (LIS) program, including the reduction of cost sharing for subsidy-eligible individuals.

      This policy requires plans to accept certain forms of documentation for a beneficiary’s eligibility for LIS, to change the beneficiary’s cost-sharing levels in the plans system based on that documentation, and for LIS beneficiaries to submit to CMS requests for correction of the data in their system if the changes do not occur as a result of routine State reporting.

      More information about Best Available Evidence (Please note that by clicking on this link, you will leave Fidelis Care’s website).

      Mail Order Prescription Drugs

      Mail Order Enrollment Form (PDF)

      You can have your medications delivered directly to your home, so you don’t have to make unnecessary trips to the local pharmacy. Not only does this service save you time, it also saves you money. Typically, you can get a 90-day supply of your medication for the price you would pay for two 30-day supplies picked up at the pharmacy counter.

      You’ll receive these benefits: 
      •  Cost savings:  One 90-day supply may cost less than two 30-day supplies at a retail pharmacy
      •  Greater convenience: At-home delivery at no extra cost, and easy refills online or by phone
      •  Quality and safety: Dedicated pharmacists checking each and every order
      •  Added value: 24/7 access to pharmacists, and alert messages by e-mail, text, or phone

      Mail Order Durable Medical Equipment

      For your convenience, Fidelis Care offers direct mail options to fill your durable medical equipment needs. These providers offer a wide range of supplies such as diabetes test strips, bladder control pads, bandages, and more.

      • Byram Healthcare. Call 1-877-902-9726, and a customer service representative will assist you with your order. You also can download order forms and fax them to 1-866-811-4500. Online reordering is available at Byram’s website,
      • Edgepark Medical Supplies. Call 1-800-321-0591 or visit to place an order.

      Clicking the links above will cause you to leave the Fidelis Care website


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      Fidelis Legacy Plan is an HMO plan with a Medicare contract. Enrollment in Fidelis Care depends on contract renewal.
      Fidelis Legacy Plan is a Coordinated Care plan with a Medicare contract and a contract with the New York State Department of Health Medicaid program. Enrollment in Fidelis Care depends on contract renewal.

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      CVS Caremark

      Fidelis Care's pharmacy partner, CVS Caremark, offers tools that make managing your prescriptions easier.

      (By clicking this link, you will leave the Fidelis Care website.) 

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