Authorization Grids

Authorization Grids are now available for Medicare, Medicaid, Child Health Plus, and NY State of Health Marketplace plans, and are effective for dates of service occurring on or after the dates below.

 

Part II: Formulary Removals & PA/ST/QL Additions


Drug Action Formulary Alternatives Effective Date
Siliq* Remove • Actemra, Stelara, Humira, Enbrel, Cosentyx, Infliximab 04/01/2022
Kevzara* Remove • Actemra, Stelara, Humira, Enbrel, Cosentyx, Infliximab 04/01/2022
Xeljanz* Remove • Actemra, Stelara, Humira, Enbrel, Cosentyx, Infliximab 04/01/2022
Xyrem Remove

• Modafinil, Armodafinil
• Venlafaxine IR/ER, Fluoxetine, Atomoxetine

04/01/2022

* Change for CHP Only; Change will not affect NYM/HARP

Medicaid Formulary and Q2 Updates


Medicaid, Child Health Plus, and Healthier Life:
Formulary Changes and Effective Dates

Fidelis Care has made changes to our Medicaid Managed Care, Child Health Plus (CHP), and HealthierLife (HARP) Formulary effective April 1, 2022. Some of the changes relate to quantity limitations, authorization requirements, as well as drugs being removed and added to the formulary. Please see the full list here.


 

Drug Action Effective Date
Buprenorphine/Naloxone (Zubsolv)** • Add with QL 03/22/2022
Buprenorphine/Naloxone film (Suboxone)**  • Add generic with QL (Brand already Formulary) 03/22/2022
Naloxone (Kloxxado)** • Add 03/22/2022
Memantine ER • Add with ST of memantine IR 04/01/2022
Procrit/Epogen • Add with PA 04/01/2022
Ruconest • Add with PA 04/01/2022
Cinryze • Add with PA 04/01/2022
Invega Hafyera • Add with PA 04/01/2022
Teriflunomide (Aubagio) • Add QL 04/01/2022
Ambrisentan (Letairis) • Add QL 04/01/2022
Fingolimod (Gilenya) • Add QL 04/01/2022
Sponimod (Mayzent) • Add QL 04/01/2022
Sponimod (Mayzent) Titration Pack • Add with QL 04/01/2022
Actemra* • Add with PA/QL 04/01/2022
Stelara* • Add with QL 04/01/2022
Buprenorphine/Naloxone (Zubsolv)** • Add with QL 04/01/2022

* Change for CHP Only; Change will not affect NYM/HARP
** Change for NYM/HARP Only; Change will not affect CHP

Medicaid, Child Health Plus, and Healthier Life:
Formulary Changes and Effective Dates

Fidelis Care has made changes to our Medicaid Managed Care, Child Health Plus (CHP), and HealthierLife (HARP) Formulary effective April 1, 2022. Some of the changes relate to quantity limitations, authorization requirements, as well as drugs being removed and added to the formulary. Please see the full list here.


 

Drug Action Effective Date
Buprenorphine/Naloxone (Zubsolv)** • Add with QL 03/22/2022
Buprenorphine/Naloxone film (Suboxone)**  • Add generic with QL (Brand already Formulary) 03/22/2022
Naloxone (Kloxxado)** • Add 03/22/2022
Memantine ER • Add with ST of memantine IR 04/01/2022
Procrit/Epogen • Add with PA 04/01/2022
Ruconest • Add with PA 04/01/2022
Cinryze • Add with PA 04/01/2022
Invega Hafyera • Add with PA 04/01/2022
Teriflunomide (Aubagio) • Add QL 04/01/2022
Ambrisentan (Letairis) • Add QL 04/01/2022
Fingolimod (Gilenya) • Add QL 04/01/2022
Sponimod (Mayzent) • Add QL 04/01/2022
Sponimod (Mayzent) Titration Pack • Add with QL 04/01/2022
Actemra* • Add with PA/QL 04/01/2022
Stelara* • Add with QL 04/01/2022
Buprenorphine/Naloxone (Zubsolv)** • Add with QL 04/01/2022

* Change for CHP Only; Change will not affect NYM/HARP
** Change for NYM/HARP Only; Change will not affect CHP

 

eviCore Healthcare

Access the eviCore utilization management system.

Manuals and Forms

Provider manuals, tip sheets, important forms, and applications. 

Pharmacy Services

Formularies, utilization management programs, general pharmacy updates, and specialty drug programs. 

Provider Access Online

Verify member eligibility/renewal, check claims status, and more.