Important Forms & Information

The Specialty Pharmacy Drug Program offers the choice of two specialty care pharmacies to help manage and access specialty drugs.

Specialty Pharmacy Program

Complete the Formulary Addition Request Form to request a prescription drug be added to your formulary.

• Find a Pharmacy
• Baylor Scott & White Mail Order Form
• Optum Rx Mail Order Form>
• Drug Claim Reimbursement Form

*Applies to plans that utilize Optum Rx as the pharmacy benefits manager.

Initial/Renewal Prior Authorization & Exception Requests
Optum Rx 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 Optum Rx.

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

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 Optum Rx. 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

*Applies to plans that utilize Optum Rx as the pharmacy benefits manager.

Medical Benefit Drugs
For information regarding coverage policies and prior authorization submission process for drugs obtained under the medical benefit (e.g. drug to be billed on a medical claim or through “buy and bill”), see Authorization Information.

Pharmacy Benefit Drugs
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 (PHARMACY benefit claims only):
Submitting drug coverage requests electronically is the most convenient way to submit a drug coverage request 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.

If submitting drug coverage requests by mail or fax, use the forms below.

• Individual Plans
  • The Essential Health Benefits formulary and applicable utilization management programs (PA requirements, step therapy requirements, quantity limits, etc.) are developed and maintained by Optum Rx. Providers can visit the links below for more information regarding Optum Rx’s PA procedures and guidelines and to access electronic PA (ePA) portals or drug coverage request forms.
    • PA procedures and guidelines (Optum Rx)
    • Drug coverage request forms:
      • Optum Rx Prior Authorization & Exception Request Form
      • Texas Standard Prescription Drug Prior Authorization Request Form
    • Coverage criteria
      • Prior Authorization Criteria/Guidelines

Individual Plans

• For members utilizing the Essential Health Benefits formulary, click here for a summary of utilization management program changes (e.g. new or revised PA criteria, step therapy requirements, quantity limit requirements, etc.)
• This document is published once a month after every P&T meeting

Pharmacy Benefit Prior Authorization Approval and Denial Rates

If you are a provider and have questions about prior authorization exemptions or gold-card status related to Texas House Bill 3459 for requests submitted to Optum Rx, visit txgoldcardfaq.com or call Optum Rx at 855-205-9182. Notices about gold-card status for requests submitted to Optum Rx are sent by Optum Rx to providers via mail. Call Optum Rx at 855-205-9182 to update your preferred method of contact or to update your contact information for gold-card status communications.

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.

• FirstCare Provider Claim Redetermination Policy
• FirstCare STAR Obstetric (OB) Ultrasounds Reimbursement Policy
• Coverage of Services for CHIP and CHIP Perinate Members

• CDC Guideline for Prescribing Opioids for Chronic Pain
• ADHD Clinical Guideline
• Asthma Guideline
• COPD Assessment Management and Use of Spirometry Guideline
• Depression Screening and Follow-Up Guideline
• Hypertension Management Guideline