Pharmacy Resources

Pharmacy Benefit Drugs

Capital Rx processes prior authorization & exception requests for drugs obtained under the prescription drug benefit (i.e. pharmacy benefit), on behalf of Scott and White Health Plan d/b/a Baylor Scott & White Health Plan, Baylor Scott & White Insurance Company and Scott & White Care Plans d/b/a Baylor Scott & White Care Plan.

Medicare Coverage of Continuous Glucose Monitors (CGMs), Diabetic Test Strips & Blood Glucose Meters

To submit a coverage request (organization determination) to obtain CGMs, diabetic test strips or blood glucose meters from a pharmacy, submit the request to Capital Rx using the contact information below. Not all diabetic test strips or glucose meters require an organization determination; non-preferred products and products exceeding certain quantities require an organization determination for coverage. Refer to the Evidence of Coverage (EOC) document for details.

Medical Benefit Drugs

Prior authorization requests for drugs obtained under the MEDICAL benefit are not processed by Capital Rx. For drugs that will be obtained under the MEDICAL benefit (e.g., drug will be billed on a medical claim by a provider), submit the request to BSWHP Health Services.

For more information regarding prior authorization submission process for drugs obtained under the MEDICAL benefit, refer to Medical Authorization Requests.

Pharmacy Benefit Drugs

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

Medical Benefit Drugs

For information regarding prior authorization and appeal submission process for drugs obtained under the MEDICAL benefit, refer to Medical Authorization Requests.

Pharmacy Benefit Drugs

Providers, members or authorized representatives can submit a request for drug coverage.

• Electronic Requests: Submitting drug coverage requests online is convenient. Refer to detail 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 above to initiate a request.

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.

Drug Coverage Request Forms (PHARMACY benefit claims only)

Medical Benefit Drugs

For information regarding prior authorization submission process for drugs obtained under the medical benefit, refer to Medical Authorization Requests.