Our Formulary
Pharmacy Benefit Information for Members on Individual & Family and Small Group ACA Plans
Essential Health Benefits Formulary
Monthly Essential Health Benefits Formulary Changes
Pharmacy Benefit Information for Members on Commercial & Self-Funded Plans
Group Value Formulary
Quality Limits-Group Value and Group Choice
HDHP Chronic Preventive Medication List
Monthly Group Value Formulary Changes
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
FirstCare Texas Medicaid Formulary
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
| Appeals (Redeterminations) |
| 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 myFirstCare Self-Service, once logged in, click on the Pharmacy Claims link. 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