CurrentFidelis CarePolicy N/A

Medication request / prior authorization form

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Provides the Fidelis Care medication request form and instructions for submitting pharmacy and medical benefit requests for Medicaid, HARP, Child Health Plus, Essential Plan and Qualified Health Plans; affects prescribers, providers, and pharmacies submitting medication prior authorization requests for Fidelis members.

Policy Summary

PayerFidelis Care

PolicyMedication request / prior authorization form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the medication request form and fax with supporting clinical documentation to the appropriate fax number to avoid delays.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24hnotification time (Pharmacy)

3d / 72hnotification time (Medical)

1-844-235-4852 / 1-844-235-5090fax numbers

1-888-FIDELISquestions phone

Clinical Documentation and Coverage Criteria

Required clinical information by condition/therapy

Clinical documentation expectations and examples of required supporting information for common therapy types to facilitate prior authorization decisions.

Submit relevant past/present therapy (prescription, over-the-counter, non-pharmacological, surgical, medical) and attach member chart documentation (chart notes, hard copy lab results preferred) to expedite prior authorization.

Provide baseline of the outcome prior to starting therapy (describe current status).

Indicate whether the patient has previously been on the requested medication; if yes, provide start date and explain benefit of therapy.

Include relevant clinical information for the condition/therapy requested (examples) — at least one of the following as applicable:

Rheumatoid Arthritis: past and current DMARDs, PPD results, RF.
Multiple Sclerosis (MS): past drug history, outcomes, current progress, MRI.
Erythropoietins (Procrit, Aranesp): CBC (H/H), ferritin, transferrin saturation.
Growth Hormone: growth chart, stimulation test, bone age, IGF-1, IGFBP-3, parental height.
Enteral Nutrition: documentation of feeding tube, diagnosis of malabsorption disorder, and B-code for medical benefit.
Diabetes: most recent A1C results and history of metformin use with doses.
Xolair: IgE level, results of skin/blood testing, and FEV1.
Androgens: total testosterone level collected by 10:00 AM (hard copy required).
HIV: viral load, resistance testing, tropism testing, and treatment history.
Colony Stimulating Factor: CBC with ANC.
Hepatitis C: use the specialized form found on the Fidelis Care pharmacy webpage.
Opioids > 90 MME/day: use the specialized form found on the Fidelis Care pharmacy webpage.

Coding and Billing References

Medical benefit injectable codingmixed

J-code

Field for entering applicable J-code for medical benefit (injectable/infused medications)

Opioids threshold reference

ThresholdOPIOIDS > 90 MME/day requires specialized form (see payer website)

Form locationSpecialized opioid form available at http://www.fideliscare.org/pharmacy

Action requiredAttach completed specialized opioid form with medical chart documentation to avoid delays

Submission Instructions and Provider Requirements

Documentation Required

Fidelis Care Medication Request Form and Fax Instructions

Complete the Fidelis Care Medication Request Form and fax to the appropriate number for the member's program. For Pharmacy submissions fax to 1-844-235-4852. For Medical submissions fax to 1-844-235-5090. For Medicaid, HealthierLife (HARP), and Child Health Plus Pharmacy or Medical submissions, Fidelis Care will notify you within 24 hours. For Essential Plan and Qualified Health Plans: Pharmacy submissions — notification within 24 hours; Medical submissions — Standard: within 3 business days; Expedited: within 72 hours. To avoid delays, print neatly, complete the form in its entirety, and attach supporting clinical documentation and medical chart notes. For Medical submissions, provide all pertinent information in the 'Medical Benefit Requests Only' section of the form.

Fax numbers: Pharmacy 1-844-235-4852; Medical 1-844-235-5090
For questions call 1-888-FIDELIS (1-888-343-3547)
Attach medical chart notes and hard-copy lab results when applicable

Prior Authorization

Request Type and Required Fields for Medical Benefit Requests

For medical benefit requests, indicate whether this is a Standard Request or an Expedited Request. If neither is selected, the request will be handled as a Standard Request. Complete all required fields in the 'Medical Benefit Requests Only' section to prevent processing delays.

Request type: select Standard Request or Expedited Request (default = Standard if blank)
Provide J-code and medication details: strength, route, frequency, duration, quantity
Units requested and requested date(s) of service
Facility name and servicing provider (include Tax ID / NPI). If a specialty pharmacy is the dispensing source, indicate that pharmacy as the servicing provider with Tax ID/NPI to avoid claims delays
If applicable, mark Brand only or Generic substitution OK
If non-preferred/non-formulary product is requested, attach rationale and chart notes
Include current diagnosis with ICD-10 code(s) and relevant medical history
Attach relevant supporting documentation: past/present therapies, lab results, imaging, diagnostic tests, and any condition-specific data (see examples below)

Key Definitions

Servicing Provider (for medical benefit requests)

DefinitionServicing Provider — the provider listed for medical benefit requests who will obtain the medication or administer it (include Tax ID/NPI).

Specialty pharmacy noteIf obtaining medication from a specialty pharmacy, indicate that pharmacy as the servicing provider with its Tax ID/NPI to avoid claims processing delays.

Required fieldsFor medical submissions include servicing provider name and Tax ID/NPI on the form.

AcariaHealth — participating specialty pharmacy

Network participationAcariaHealth is a participating specialty pharmacy in Fidelis Care's specialty pharmacy network.

Referral/process linkTo begin obtaining specialty medications via AcariaHealth, visit https://acariahealth.envolvehealth.com/resources/referral-forms1.html for a referral form.

Member optionsMembers may continue to obtain mail order/specialty drugs at any retail network pharmacy if that pharmacy accepts Fidelis Care's specialty network terms and conditions.

Policy Summary

PayerFidelis Care

PolicyMedication request / prior authorization form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the medication request form and fax with supporting clinical documentation to the appropriate fax number to avoid delays.

SourceLink

On This Page

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

Medication request / prior authorization form

Customize your policy alerts

Sign up for all Fidelis Care policy alerts

Know when Fidelis Care releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Clinical Documentation and Coverage Criteria

Required clinical information by condition/therapy

Clinical documentation expectations and examples of required supporting information for common therapy types to facilitate prior authorization decisions.

Provide baseline of the outcome prior to starting therapy (describe current status).

Indicate whether the patient has previously been on the requested medication; if yes, provide start date and explain benefit of therapy.

Include relevant clinical information for the condition/therapy requested (examples) — at least one of the following as applicable:

Rheumatoid Arthritis: past and current DMARDs, PPD results, RF.
Multiple Sclerosis (MS): past drug history, outcomes, current progress, MRI.
Erythropoietins (Procrit, Aranesp): CBC (H/H), ferritin, transferrin saturation.
Growth Hormone: growth chart, stimulation test, bone age, IGF-1, IGFBP-3, parental height.
Enteral Nutrition: documentation of feeding tube, diagnosis of malabsorption disorder, and B-code for medical benefit.
Diabetes: most recent A1C results and history of metformin use with doses.
Xolair: IgE level, results of skin/blood testing, and FEV1.
Androgens: total testosterone level collected by 10:00 AM (hard copy required).
HIV: viral load, resistance testing, tropism testing, and treatment history.
Colony Stimulating Factor: CBC with ANC.
Hepatitis C: use the specialized form found on the Fidelis Care pharmacy webpage.
Opioids > 90 MME/day: use the specialized form found on the Fidelis Care pharmacy webpage.

Coding and Billing References

Medical benefit injectable codingmixed

J-code

Field for entering applicable J-code for medical benefit (injectable/infused medications)

Opioids threshold reference

ThresholdOPIOIDS > 90 MME/day requires specialized form (see payer website)

Form locationSpecialized opioid form available at http://www.fideliscare.org/pharmacy

Action requiredAttach completed specialized opioid form with medical chart documentation to avoid delays

Submission Instructions and Provider Requirements

Documentation Required

Fidelis Care Medication Request Form and Fax Instructions

Fax numbers: Pharmacy 1-844-235-4852; Medical 1-844-235-5090
For questions call 1-888-FIDELIS (1-888-343-3547)
Attach medical chart notes and hard-copy lab results when applicable

Prior Authorization

Request Type and Required Fields for Medical Benefit Requests

Request type: select Standard Request or Expedited Request (default = Standard if blank)
Provide J-code and medication details: strength, route, frequency, duration, quantity
Units requested and requested date(s) of service
Facility name and servicing provider (include Tax ID / NPI). If a specialty pharmacy is the dispensing source, indicate that pharmacy as the servicing provider with Tax ID/NPI to avoid claims delays
If applicable, mark Brand only or Generic substitution OK
If non-preferred/non-formulary product is requested, attach rationale and chart notes
Include current diagnosis with ICD-10 code(s) and relevant medical history
Attach relevant supporting documentation: past/present therapies, lab results, imaging, diagnostic tests, and any condition-specific data (see examples below)

Key Definitions

Servicing Provider (for medical benefit requests)

DefinitionServicing Provider — the provider listed for medical benefit requests who will obtain the medication or administer it (include Tax ID/NPI).

Specialty pharmacy noteIf obtaining medication from a specialty pharmacy, indicate that pharmacy as the servicing provider with its Tax ID/NPI to avoid claims processing delays.

Required fieldsFor medical submissions include servicing provider name and Tax ID/NPI on the form.

AcariaHealth — participating specialty pharmacy

Network participationAcariaHealth is a participating specialty pharmacy in Fidelis Care's specialty pharmacy network.

Referral/process linkTo begin obtaining specialty medications via AcariaHealth, visit https://acariahealth.envolvehealth.com/resources/referral-forms1.html for a referral form.

Member optionsMembers may continue to obtain mail order/specialty drugs at any retail network pharmacy if that pharmacy accepts Fidelis Care's specialty network terms and conditions.