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Get NY Fidelis Care Medication Request Form For Hepatitis C (HCV) Agents 2015-2024

"877"533"2405.!Fidelis!Care!will!notify!you!within!3*business*days!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*ensure*that*you*complete*the*form*in*its*entirety*and*print*neatly*to*help*expedite*the*drug*coverage*review*process.*Provision!of! the!information!requested!on!this!form!does%not%guarantee!coverage.!This!list!is!not!all inclusive! !please!submit.

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