Pharmacy Information

Our FirstCare HMO plans and FirstCare PPO plans include a prescription drug benefit. This benefit program offers broad prescription drug coverage, and allows you to share in the savings when you and your doctor decide on certain medications.

Note: Some of our prescription drug plans have a separate medication deductible. This is indicated in your plan’s details.

Our Formulary

Pharmacy Benefit Information for Members on Small Group ACA Plans
2020 Essential Health Benefits Formulary
2021 Essential Health Benefits Formulary
Monthly Essential Health Benefits Formulary Changes

Pharmacy Benefit Information for Members on Commercial & Self-Funded Plans
Group Value Formulary
Quantity Limits-Group Value
HDHP Chronic Preventive Medication List
Monthly Group Value Formulary Changes

Preventive Care Medications

Under the Affordable Care Act, also known as the health care reform law, FirstCare covers some preventive care medications at 100% without charging a copay, coinsurance or deductible. The following list of drugs and products require a prescription (including over-the-counter medications) and must be filled at a network pharmacy to be covered at no cost share.
Group Value Preventive Medication List
Essential Health Benefits Preventive Medication List

Specialty Pharmacy Drug Program

The Specialty Pharmacy Drug Program offers the choice of two specialty care pharmacies to help manage and access specialty drugs. (Not applicable to Medicare plans.)
Specialty Pharmacy Program

Pharmacy Information

Find a Pharmacy
Baylor Scott & White Mail Order Form
OptumRx Mail Order Form
Drug Claim Reimbursement Form

Pharmacy Benefit Drug Requests — Prior Authorizations, Exceptions & Appeals

Initial/Renewal Prior Authorization & Exception Requests
OptumRx processes prior authorization (PA) & exception requests for drugs obtained under the prescription drug benefit (i.e. pharmacy benefit), on behalf of FirstCare Health Plans. To request prior authorization or an exception for a drug that will be obtained under the Pharmacy benefit, submit the request to OptumRx.

Appeal Requests
Appeal requests for drugs obtained under the Pharmacy benefit are processed by OptumRx. To request a drug coverage appeal for a Pharmacy benefit drug, submit the request to OptumRx.

Drug Prior Authorization, Exception, & Appeal Requests — Submission Details
For information regarding how to submit a drug coverage request, refer to the table below.

Drug coverage criteria require use in accordance with FDA approved labeling, drug compendia (reference books), or substantially accepted peer-reviewed scientific literature. To demonstrate the medical necessity of a requested drug, medical records and relevant clinical information should be submitted with the coverage request.

Medical Benefit Drugs
Prior authorization and appeal requests for drugs obtained under the Medical benefit are not processed by OptumRx. For more information regarding prior authorization submission process for drugs obtained under the Medical benefit (i.e. drug will be billed on a medical claim by a provider), refer to FirstCare Authorization Guidelines.

Table — Pharmacy Benefit Drug Prior Authorization, Exception, & Appeal Requests — Submission Details
Initial / Renewal PA request
  ONLINE   Members*
     MyBSWHealth Member Portal

  Providers
     CoverMyMeds
     SureScripts
     PreCheck MyScript
  FAX   1-844-403-1029
  PHONE   1-855-205-9182
  MAIL   OptumRx
  Attn: Prior Auth Exceptions
  P.O. Box 25183
  Santa Ana, CA 92799
 
Appeals (Redeterminations)
  ONLINE   Utilize links above
  FAX   1-877-239-4565
  PHONE   1-888-403-3398
  MAIL   OptumRx
  Prior Authorization Department
  c/o Appeals Coordinator
  P.O. Box 25184
  Santa Ana, CA 92799
*Log into MyBSWHealth Member Portal. Once logged in, click on “Insurance & Billing” > “Scott & White Health Plan” > “Plan Benefits” > and click “View” Pharmacy Claims. When on the OptumRx website, you can submit a prior authorization request online.

Drug Coverage Requests
Providers, members, or authorized representatives can submit a request for drug coverage.
  • Electronic requests: Submitting drug coverage requests online is convenient and allows you to track the status of your request. Refer to the table above for links to online portals to submit a drug coverage request electronically.
  • Mail or Fax requests: Drug coverage request forms can be found below. These forms can be used to submit a request by mail or fax.
  • Phone requests: Drug coverage requests can be initiated by phone. Call the applicable phone number listed in the table above to initiate a request.
Drug Coverage Request Forms:
     OptumRx Prior Authorization & Exception Request Form
     Texas Standard Prescription Drug Prior Authorization Request Form

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HMO: 1-800-884-4901
PPO: 1-800-240-3270
Administrative Services: 1-888-249-7366

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