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Your Fidelis SecureCare plan includes comprehensive coverage for Medicare Part D prescription drugs—a benefit specifically designed to protect you against the high cost of prescription medications.
On this page you will find complete information about your Part D coverage, including:
About the Fidelis Formulary
The Fidelis Formulary is the list of drugs covered by your Fidelis SecureCare plan. It includes those medications most often needed by our Members. As a member of our plan you have over 60,000 pharmacies in your network to choose from. Our network of pharmacies meets CMS requirements for pharmacy access in your area. It is important to fill your prescriptions at these network pharmacies to get the most out of your benefits. For a complete list of Fidelis network pharmacies, click here.
Our formularies are updated from time to time when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. All medications are reviewed on a regular basis by medical and pharmacy professionals. You can use our electronic Drug Search tool to quickly check whether your prescription medicine is covered by your plan. This comprehensive electronic library will give you the most current details about your medicine, including
- Part B and D coverage status
- The drug’s assigned formulary tier
- The quantity limitation for your plan
- Information on lower cost alternatives (when applicable)
- Whether or not Prior Authorization (PA) is required
Should your medicine require Prior Authorization, you or your physician can download the appropriate request form immediately. Or, if your prescription medicine is not found in the formulary, the Request for Coverage of a Non-Formulary Drug form is available on the same page.
For the Fidelis Formulary Drug Search tool, click here
To view the Fidelis Formulary, click here.
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The chart below details the Part D Prescription Drug benefit for each of our plans.
Part D Prescription Drug Benefit Plan Summary
| North Carolina |
|
Fidelis Secure Comfort HMO SNP |
Fidelis Secure Comfort Plus HMO SNP |
Fidelis Secure Independence HMO SNP |
| Monthly Plan Premium |
$34.80 |
$98.00 |
$120.00 |
| Monthly plan premium includes your medical and your Part D Prescription Drug coverage. |
| Yearly Deductible |
$310 |
$0 |
$0 |
| Initial Coverage |
After the annual deductible you pay:
|
IN-NETWORK
RETAIL & LONG TERM CARE PHARMACY
Generic - $5 for a 1 month supply
Preferred Brand: $30 for 1 month supply
Non-Preferred Brand: $65 for 1 month supply
Specialty: 33%
MAIL ORDER
Generic: $5 for a 3 month supply
Preferred Brand: $60 for 3 month supply
Non-Preferred Brand: $130 for 3 month supply
Specialty: 33% |
|
25% of Medicare-approved amounts
Up to $2840 in total annual drug costs (paid by you and your plan) at in-network pharmacies |
| After $2,840 Coverage Limit |
You pay |
|
You receive a discount on brand name drugs and you pay only 93% of the costs of generic drugs. |
| Catastrophic Coverage |
After $4,550, you pay |
|
The greater of 5% coinsurance or a $2.50 copay for generic drug or $6.30 for all other drugs |
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General information for all Fidelis Prescription Drug Plans
- Certain prescription drugs will have maximum quantity limits
- Your provider must get prior authorization from Fidelis for certain prescription drugs
- Covered Part D drugs are available at out-of-network pharmacies in special circumstances including illness while traveling outside of the plan’s service area where there is no network pharmacy
- Drugs received at an out-of-network pharmacy may incur additional cost
- People who have limited incomes, who live in long term care communities, or have access to Indian/tribal/Urban (Indian Health Service) facilities may have different out-of-pocket costs. Contact your plan for details.
To download a Out-of-Network Pharmacy Claim Form, click here.
To download a Mail Order Pharmacy Form, click here. Back to top
Cost-effective Generic Drugs
 The Fidelis SecureCare formulary uses tiers, or levels, to show you which drugs are available at which prices. Often, generic drugs are the most cost-effective choices. They usually appear on Tier 1, at the lowest prices.
Preferred, Non-Preferred & Brand Help
Fidelis SecureCare plans provide additional savings on brand name drugs by offering our members Preferred Brand and Non-preferred Brand options. Preferred Brand drugs are available at lower coinsurance/co-pay levels than Non-preferred Brands.
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Prescription Transition Policy
New members in our plan may be taking drugs that are not on our formulary or that are subject to certain restrictions, such as prior authorization or step therapy. Members should talk to their doctors to decide if they should switch to an appropriate drug that we cover or request a formulary exception (which is a type of coverage determination) in order to get coverage for the drug. While these new members might talk to their doctors to determine the right course of action, we may cover the non-formulary drug in certain cases during the first 90 days of new membership.
For each of the drugs that is not on our formulary or that have coverage restrictions or limits, we will cover a temporary 31-day supply (unless the prescription is written for fewer days) when the new member goes to a network pharmacy (and the drug is otherwise a Part D drug). After the first 31-day supply, we will not pay for these drugs, even if the new member has been a member of the plan less than 90 days.
If the new member resides in a nursing home or assisted living community, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days for a new member of our plan. If a new member needs a drug that is not on our formulary or is subject to other restrictions, such as step therapy or dosage limits, but the new member is past the first 90 days of new membership in our plan, we will cover a 31-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception.
Please note that our transition policy applies only to those drugs that are Part D drugs purchased at a network pharmacy. The transition policy cannot be used to purchase a non-Part D drug or drug out-of-network.
In some cases, we will contact you if you are taking a drug that is not on our formulary. We can give you the names of covered drugs that also are used to treat your condition so you can ask your doctor if any of these drugs is an option for your treatment.
To download the Medicare Prescription Drug Coverage Determination Form for requests such as, a lower co-pay, quantity limit exception, step therapy exception or coverage of a non-formulary drug, click here.
Instructions for completing a coverage determination request form:
1. The patient and/or their provider must complete the Request for Medicare Prescription Drug Coverage Determination Form in its entirety.
2. The form should be mailed to:
Prior Authorization Department
3515 Harbor Blvd.
Costa Mesa, CA 92626
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Grievance and Appeals Process
A grievance is a type of complaint you make about us or one of our plan providers, including a complaint concerning the quality of your care. This type of complaint does not involve payment or coverage disputes.
An appeal is a type of complaint you make when you want us to reconsider and change a decision we have made about what services are covered for you or what we will pay for a service.
For complete information on the Grievance and Appeals process, click here.
For Medicare Prescription Drug Appeals and Grievances Forms, click here.
To visit the Office of the Medicare Beneficiary Ombudsman, click here.
To file a Medicare Complaint Form, click here.
As an enrollee, you should have received a copy of the Evidence of Coverage booklet. If you do not have a copy, you may download one below. See Chapter 9 for more information on the grievance coverage determination (including exceptions) and appeals processes.
2012 Fidelis Secure Plans
Fidelis Secure Comfort
Fidelis Secure Comfort Plus
Fidelis Secure Independence
Fidelis Secure Freedom
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Appointing a Representative
To consider a request from someone other than the member, Fidelis SecureCare must obtain authorization. You may appoint any individual as your representative by sending Fidelis SecureCare an Appointment of Representative Form signed by both you and your representative. A representative who is appointed by the court or who is acting in accordance with state law may also file a request on your behalf after sending Fidelis the legal representative document. You will not need to complete an Appointment of Representative Form if you provide another legal representation document with your request.
To download the Appointment of Representation Form, click here.
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Additional Help for Low Income Beneficiaries
You may be one of the millions of beneficiaries who will qualify for reduced premiums and increased cost-sharing. Additional support may be available depending on your financial situation (taking into consideration your assets, savings and stocks, but not including the value of your home).
For more information about this support, call 1-800-MEDICARE (1-800-633-4227) or your local Social Security office.
To view the Fidelis SecureCare premium summary chart for low income beneficiaries, click here.
For Best Available Evidence (BAE) Information, click here.
About the CMS BAE Policy
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