Coverage Determination
The coverage determination process for prior authorization ensures that medication regimens that are high risk, have a high potential for misuse, or narrow therapeutic indices are used appropriately and according to FDA-approved indications.
- Electronic Prior Authorization (ePA): Cover My Meds
- Online: Request Prescription Drug Coverage
- Fax or Mail: Coverage Determination Form (PDF)
The coverage determination process is required for:
- Duplication of therapy
- Prescriptions that exceed the FDA daily or monthly quantity limit
- Most self-injectable and infusion medications (including chemotherapy)
- Drugs not listed on the PDL
- Drugs that have an age edit
- Drugs listed on the PDL but still require Prior Authorization (PA)
- Brand name drugs when a generic exists
- Drugs that have a step therapy edit and the first-line therapy is inappropriate
Formulary Medication For Treatment Naïve Patients*
(no previous treatment within a 2 year period):
a. Patient is treatment naïve and has a confirmed diagnosis of hepatitis C; AND
b. Formulary Medication is age-appropriate according to FDA-approved package labeling, nationally recognized compendia, or peer-reviewed medical literature.
*Please note coverage will be provided via a Smart Prior Authorization system where applicable
As of January 1, 2026 Fidelis Care is participating in the CMS Cell and Gene Therapy (CGT) Access Model in the State of New Jersey.