Get the free fidelis care medication request form

Requested Medications Zepatier once daily Epclusa once daily Harvoni once daily Daklinza 30mg once daily Sovaldi 400mg once daily 200mg dosing schedule Please note generic 200mg is the preferred product Branded formulations of are non-formulary 11. Prescriber s Signature Reminder Before Submitting see points above for details and hard copy requirements Prior Authorization Checklist Completed form provider information and questions 1- 12 Chart notes as needed Laboratory results Genotype HCV...

How to fill out fidelis care medication request

How to fill out fidelis care medication request

1. To fill out the Fidelis Care medication request, follow these steps:
2. Obtain the Fidelis Care medication request form from your healthcare provider or download it from their website.
3. Fill in your personal information, including your name, address, and contact details.
4. Provide your Fidelis Care member ID number, which can be found on your insurance card.
5. Specify the medication details, such as the name, dosage, and frequency of the prescription.
6. Include any additional information or special instructions from your healthcare provider.
7. Attach any supporting documentation, if required, such as prior authorization forms.
8. Review the completed form to ensure all the information is accurate and legible.
9. Submit the filled-out medication request form to Fidelis Care through the designated channels, such as mail or online submission.
10. Keep a copy of the completed form for your records.
11. Wait for Fidelis Care to process your medication request and communicate the status to you.

Who needs fidelis care medication request?

1. Anyone who is a member of Fidelis Care and requires medication prescribed by their healthcare provider needs to fill out the Fidelis Care medication request. This can include individuals with chronic conditions, acute illnesses, or those undergoing specific treatments that require prescription medication. The request ensures that Fidelis Care can review and authorize the medication as part of their coverage.

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What is fidelis care medication request?

Fidelis Care Medication Request is a form that needs to be submitted by healthcare providers to request coverage for certain medications for Fidelis Care members.

Who is required to file fidelis care medication request?

Healthcare providers are required to file Fidelis Care Medication Request on behalf of their patients.

How to fill out fidelis care medication request?

Fidelis Care Medication Request can be filled out by healthcare providers with necessary patient information, medication details, and justification for coverage.

What is the purpose of fidelis care medication request?

The purpose of Fidelis Care Medication Request is to request coverage for specific medications for Fidelis Care members to ensure they receive the prescribed treatment.

What information must be reported on fidelis care medication request?

Fidelis Care Medication Request must include patient's information, medication details, diagnosis, prescriber's information, and justification for coverage.