Medication Request Form for MMC, HARP, CHP, EP & QHP

FIDELIS CARE MEDICATION REQUEST FORM (6/2024)

Medicaid, HealthierLife (HARP), Child Health Plus, Essential Plan and Qualified Health Plans

Complete form and fax to 1-844-235-4852 (Pharmacy) or 1-844-235-5090 (Medical). For Medicaid, HealthierLife (HARP), and Child Health Plus

Pharmacy or Medical submissions, Fidelis Care will notify you within 24 hours as to what determination has been made. For Essential Plan and

Qualified Health Plans Pharmacy Submissions, Fidelis Care will notify you within 24 hours as to what determination has been made, and for Medical

Submissions, Fidelis Care will notify you within 3 Business Days (Standard) or 72 hours (Expedited) as to what determination has been made. If

you have any questions, please dial 1-888-FIDELIS (1-888-343-3547) and follow the appropriate prompts. To avoid unnecessary delays, PLEASE

PRINT NEATLY AND COMPLETE THE FORM IN ITS ENTIRETY AND ATTACH ADDITIONAL JUSTIFICATION AND MEDICAL CHART NOTES. For Medical

submissions, PLEASE PROVIDE ALL PERTINENT INFORMATION IN THE ‘MEDICAL BENEFIT REQUESTS ONLY’ SECTION.

Member name (last, first) ________________________________________________ Member ID # _______________________________

DOB ______/______/______ Age _____________ Height _____________ Weight _____________ Sex Male  Female 

Prescriber name ___________________________________ Specialty ___________________ Contact Person ______________________

Address ____________________________________________________ City ____________________________ST ________Zip _______

Phone #______________________________________ Ext ___________ Fax # _______________________________________________

MEDICAL BENEFIT REQUESTS ONLY: J-code ______________________________________ Units Requested ____________________

Requested date(s) of service: _____________________ Facility Name _________________ _

Servicing Provider* ______________________________________________ Tax ID # / NPI # ______________________

* If obtaining medication from a specialty pharmacy, please indicate the pharmacy as the servicing provider with Tax ID/NPI to avoid delays in claims processing.

Standard Request  Expedited Request 

** If neither of the above two selections are made, the case will be handled as a Standard Request

Medication Requested (strength, route, frequency, duration, and quantity) Brand name only  Generic substitution OK 

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Important Note regarding Specialty Medications (Excluding Medicare and Qualified Health Plans): AcariaHealth, a specialty pharmacy, is participating in

Fidelis Care’s specialty pharmacy network. If you choose to use AcariaHealth they will work directly with you to obtain and fill your prescription(s), and to

ensure that they are delivered in a timely and accurate manner, per your preference: your patient, your practice, or the medical professional who will be

administering the medication. Members can continue to obtain mail order/specialty drugs at any retail network pharmacy, as long as that retail network

pharmacy accepts Fidelis Care’s specialty network terms and conditions. To begin the process of obtaining specialty medications for your patients visit

https://acariahealth.envolvehealth.com/resources/referral-forms1.html for a referral form.

If applicable, please provide rationale for need of non-preferred / non-formulary product (attach medical chart notes) ___________________

__________________________________________________________________________________________________________________

Current Diagnosis / ICD-10 and Other Medical History (attach medical chart notes) __________________________________________________________

Relevant lab results, x-rays, diagnostic tests supporting request, or verify absence of contraindications (hard copy lab results required)

__________________________________________________________________________________________________________________

Please submit Relevant past/present therapy (Prescription, Over-the-Counter, non-pharmacological, surgical medical etc.). Please attach this information

and documentation from the member’s chart to expedite the prior authorization process.

What is the baseline of this outcome prior to starting therapy? _____________________________________________________________

_______________________________________________________________________________________________________________

Has the patient previously been on the requested medication? Yes  No  (If yes, provide start date and explain benefit of therapy)

_______________________________________________________________________________________________________________

IMPORTANT: Please provide relevant clinical information that will help us to facilitate processing of your request including but not limited to: (MUST BE INCLUDED

TO AVOID DELAYS; member chart notes, hard copy of lab results preferred)

• Rheumatoid Arthritis: past and current DMARDs, PPD results, RF

• Multiple Sclerosis (MS): past drug history, outcomes, current progress, MRI

• Erythropoetins (Procrit, Aranesp): CBC (H/H), ferritin, transferrin saturation

• Growth Hormone: growth chart, stim test, bone age, IGF1, IGFBP3, parental height

• Enteral Nutrition: feeding tube, malabsorption disorder, Bcode 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)

• Hepatitis C: see specialized form found at http://www.fideliscare.org/pharmacy

• OPIOIDS > 90 MME/day: see specialized form found at

http://www.fideliscare.org/pharmacy

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I attest that this information is accurate and true, and that the supporting documentation is available for review upon request of said plan, the NYSDOH or CMS. I understand that any person who knowingly

makes or causes to be made a false record or statement that is material to a Medicaid MC claim may be subject to civil penalties and treble damages under both federal and NYS False Claims Acts.

Prescriber's Signature __________________________________________________________________________Date_________________