Marketplace Pharmacy Information

Every FirstCare Marketplace plan includes benefits for your prescription drugs. These prescription drug benefits offer broad prescription drug coverage, and allow you to share in the savings when you and your doctor decide on certain medications.

Our Formulary

2023 Essential Health Benefits Formulary
2023 HDHP Chronic Preventive Medication List
2022 Essential Health Benefits Formulary
2022 HDHP Chronic Preventive Medication List
Monthly Essential Health Benefits 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.

2023 Essential Health Benefits Preventive Medication List
2022 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.

Specialty Pharmacy Drug Program

Pharmacy Information

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

Need More Detailed Pharmacy Information?

To learn more about your prescription drug costs for the Individual Plans, use the link below: Prescription Drug Cost Calculator

Pharmacy Benefit Drug Requests — Prior Authorizations, Exceptions & Appeals

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

Initial / Renewal PA request
ONLINE	Members*      MyBSWHealth Member Portal
FAX	1-844-403-1029
PHONE	1-855-205-9182
MAIL	Optum Rx Prior Authorization   P.O. Box 2975   Mission, KS 66201

 

Appeals (Redeterminations)
ONLINE	Utilize links above
FAX	1-877-239-4565
PHONE	1-888-403-3398
MAIL	Optum Rx Prior Authorization Appeals   P.O. Box 2975   Mission, KS 66201

*Log into MyBSWHealth Member Portal. Once logged in, click on “Insurance & Billing” > “Baylor Scott & White Health Plan” > “Plan Benefits” > and click “View” Pharmacy Claims. When on the Optum Rx 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:
     Optum Rx Prior Authorization & Exception Request Form
     Texas Standard Prescription Drug Prior Authorization Request Form