Important Forms & Information

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  FirstCare Prior Authorization Request Form

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  Psychological Testing Request Form

  Psychological/Neuropsychological Testing Prior Authorization Request Form

 

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  2018 Commercial Formulary

  Effective 1/1/2018; includes details on prior authorizations, step therapy & quantity limits

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  2018 ACA Marketplace Formulary

  Effective 1/1/2018; includes details on prior authorizations, step therapy & quantity limits

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  Formulary Updates

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  Specialty Pharmacy Enrollment Form (Lumicera)

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  Mail Order Pharmacy Enrollment Guide (Novixus)

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  Mail Order Pharmacy FAQs (Novixus)

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  Texas Standard Prior Authorization Request Form for Prescription Drugs

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  Exception Request Form

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  Botulinum Toxins - Prior Authorization Form

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  Preferred Vicosupplements - Prior Authorization Form

 

   
FirstCare has developed Reimbursement Policies, which include coding information, to provide you with ready-access and general guidance on payment methodologies for medical, surgical and behavioral health services.

These policies are subject to all terms of the Provider Service Agreement as well as changes, updates and other Reimbursement Policy requirements. All of these policies are also subject to federal HIPAA rules, and in the case of medical code sets (HCPCS, CPT, ICD-10), FirstCare accepts codes valid for the date(s) of service. Additionally, Reimbursement Policies supplement certain standard FirstCare benefit plans and aid in administering benefits. Thus, federal and state law, contract language, etc., take precedence over the language in the policies—i.e., Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs) and/or other published documents. Moreover, the terms of a member’s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from these Reimbursement Policies. For example, a member’s benefit plan may contain specific exclusions related to the topic addressed in Reimbursement Policies.

Most importantly, our Reimbursement Policies relate exclusively to the administration of health benefit plans and are not recommendations for treatment or treatment guidelines. Providers are responsible for the treatment and recommendations provided to the member.

All Reimbursement Policies are subject to change prior to the annual review date. FirstCare lines of business (LOB) are subject to change without notice; individual Reimbursement Policies list the applicable LOBs.