CurrentFidelis CarePolicy N/A

Medication request / prior authorization form

Form and process for submitting medication requests (pharmacy and medical benefit) for Fidelis Care members across Medicaid, HARP, Child Health Plus, Essential Plan and Qualified Health Plans; directs providers on submission methods, timelines, and required documentation.

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 and fax the medication request form to the Pharmacy fax (1-844-235-4852) or Medical fax (1-844-235-5090).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 hoursPharmacy notification timeframe (selected products)

3 business daysMedical notification timeframe (Essential/QHP)

1-844-235-4852 / 1-844-235-5090Submission faxes

1-888-FIDELISHelp line

Coverage and Documentation Criteria

Coverage and documentation criteria

Documentation and clinical information required to process authorization requests; include the completed form, provider/member identifiers, medication details, and any disease-specific labs or history.

ALL of the following

ALL of the following
- Completed medication request form with member and provider identifiers (facility name, servicing provider, Tax ID/NPI).
- If obtaining medication from a specialty pharmacy, indicate the pharmacy as the servicing provider with Tax ID/NPI to avoid claims delays.
ALL of the following
- Medication requested including strength, route, frequency, duration, quantity, and whether brand only or generic substitution is acceptable.

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 and fax the medication request form to the Pharmacy fax (1-844-235-4852) or Medical fax (1-844-235-5090).

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ALL of the following

Examples include
- Rheumatoid Arthritis: past and current DMARDs, PPD results, RF.
- Multiple Sclerosis: past drug history, outcomes, current progress, MRI.
- Erythropoietins (Procrit, Aranesp): CBC (H/H), ferritin, transferrin saturation.
- Growth Hormone: growth chart, stim test, bone age, IGF-1, IGFBP3, parental height.
- Enteral Nutrition: feeding tube, malabsorption disorder, B-code for medical benefit.
- Diabetes: latest A1C results, past metformin use with doses.
- Xolair: IgE level, results of skin/blood test, FEV1.
- Androgens: total testosterone level collected by 10am (hard copy required).
- HIV: viral load, resistance testing, tropism testing, treatment history.
- Colony Stimulating Factor: CBC (ANC).

Submission Instructions and Required Documentation

Prior Authorization

Submission Instructions — fax the completed medication request form

Complete and fax the Fidelis Care Medication Request Form to the appropriate fax number: 1-844-235-4852 (Pharmacy) or 1-844-235-5090 (Medical). For Medicaid, HealthierLife (HARP), and Child Health Plus submissions Fidelis Care will notify you within 24 hours. For Essential Plan and Qualified Health Plans: Pharmacy submissions — notify within 24 hours; Medical submissions — notify within 3 business days (Standard) or 72 hours (Expedited). To avoid delays, print neatly, complete the form in its entirety, and attach additional justification and medical chart notes. For Medical submissions, include all pertinent information in the “MEDICAL BENEFIT REQUESTS ONLY” section.

Fax Pharmacy: 1-844-235-4852
Fax Medical: 1-844-235-5090
Questions: 1-888-FIDELIS (1-888-343-3547)

Documentation Required

Request Timing and Medical Benefit Documentation Requirements

For J-code (medical benefit) requests indicate whether the request is Standard or Expedited. If neither box is selected on the form, the request will be handled as Standard. Include facility name, servicing provider or specialty pharmacy (identify pharmacy as servicing provider if applicable), units requested, requested dates of service, and Tax ID/NPI to avoid claims processing delays.

Select Standard or Expedited — default = Standard if neither selected
Provide facility name and servicing provider (or specialty pharmacy)
Include units, dates of service, and Tax ID/NPI

Documentation Required

Clinical History Required

Provide a comprehensive clinical history to support the request. Attach member chart notes and hard copy lab results where indicated. Include past and present therapies (prescription, OTC, non‑pharmacological, surgical), baseline outcome measures prior to therapy, and whether the patient has previously used the requested medication (with start date and explanation of benefit).

List past and current therapies with dates and doses as applicable (prescription, OTC, non‑pharmacologic, surgical).
State the baseline for the relevant outcome prior to starting therapy.
Indicate prior use of the requested medication — Yes/No; if Yes provide start date and response/benefit.

Documentation Required

Condition‑Specific Clinical Data to Include

Include condition‑specific supporting data where applicable. The following examples illustrate the types of documentation required to avoid delays; provide the corresponding items when relevant to the request.

Rheumatoid Arthritis: past and current DMARDs, PPD results, rheumatoid factor (RF)
Multiple Sclerosis: past drug history, outcomes, current progress notes, MRI
Erythropoietins: 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, malabsorption disorder, B‑code for medical benefit
Diabetes: latest A1C and prior metformin use with doses
Xolair: IgE level, skin/blood test results, FEV1
Androgens: total testosterone collected by 10am (hard copy required)
HIV: viral load, resistance testing, tropism testing, treatment history
Colony Stimulating Factor: CBC (ANC)
Hepatitis C and Opioids >90 MME/day: use specialized forms available at fideliscare.org/pharmacy

Request Type Definitions

Expedited Request

DefinitionExpedited Request — provider selection indicating the need for faster review than Standard Request.

Form selectionMark the 'Expedited Request' box on the medical benefit (J-code) request form to trigger expedited processing.

Documentation expectationInclude full supporting documentation (chart notes, hard-copy lab results) with the request to facilitate timely expedited review.

When to useUse when clinical circumstances require quicker determination than the Standard Request timeframe.

Standard Request

DefinitionStandard Request — the default processing category for prior authorization requests when no selection is made.

Form handlingIf neither 'Standard' nor 'Expedited' is selected on the J-code request form, the case will be handled as a Standard Request.

Expected processingStandard processing timelines apply unless expedited selection and justification are provided.

OpenPayer

Medication request / prior authorization form

Coverage and Documentation Criteria

Codes and Special Categories

Submission Instructions and Required Documentation

Request Type Definitions