Pharmacy
Fidelis Care is committed to working with providers to improve members' health and well-being. The following information will help your patients get the most out of their pharmacy benefits.
Coverage Determination
The Coverage Determination process enables providers to request an addition or exception.
Medication Appeals
Providers may appeal a coverage determination decision by contacting our Pharmacy Appeals department via fax, mail, in person or phone. Please refer to the Quick Reference Guide for instructions.
- Online: Request Appeal for Drug Coverage using our online form
- Fax or Mail: Complete an Appeal of Coverage Determination Request (PDF)
Preferred Drug List (PDL)
The Preferred Drug List contains information about drugs covered by the plan. Please check back for updates, as PDLs are periodically amended. Search for a drug using our online tool, or view or print the PDL.
Printed Preferred Drug Lists
- New Jersey Medicaid Preferred Drug List (PDF)
- New Jersey Medicaid Machine Readable File
- New Jersey Medicaid Notice of Change (PDF) Effective 07/01/2025 & 08/01/2025
- New Jersey Medicaid Notice of Change (PDF) Effective 08/01/2025 - DIABETIC TESTING SUPPLIES
- New Jersey Medicaid Notice of Change (PDF) Effective 03/01/2026
- New Jersey Medicaid Notice of Change (PDF) Effective 06/01/2026
- Diabetes Testing Supply Accu-Chek Meter Information (PDF)
Other Helpful Information
Under the Affordable Care Act (ACA) and the 21st Century Cures Act, all practitioners who prescribe, order, or refer services for Medicaid recipients must be enrolled as Medicaid providers.
As a result, services are only eligible for reimbursement if the ordering, prescribing, or referring (OPR) provider, and dispensing pharmacy is enrolled in the applicable state Medicaid program.
To align with New Jersey Medicaid and Centers for Medicare & Medicaid Services (CMS) requirements, effective August 17, 2026, Fidelis Care will begin enforcing edits on pharmacy claims via our pharmacy benefits manager (Express Scripts) to verify the presence of an enrolled OPR provider.
Key requirements:
- All pharmacy claims must include the NPI of the OPR provider
- The OPR provider must be enrolled in NJ Medicaid
- Claims missing a valid OPR NPI will be denied
Provider Enrollment Resources:
- NJ Medicaid (NJMMIS): www.njmmis.com/providerEnrollment.aspx | 609-588-6036
- NJ Fidelis: 888-453-2534
AcariaHealth Specialty Pharmacy offers expert service in the special handling, storage and administration of medications for Fidelis Care members who have long-term, life-threatening or rare conditions. With its knowledge of the insurance process and plan benefits, the team can speedily help the patient receive his or her medication. For a detailed list of conditions covered, please visit our AcariaHealth Specialty Pharmacy page.