Drug Requests — Prior Authorizations, Exceptions & Appeals
Initial/Renewal prior authorization & exception requests
PHARMACY BENEFIT DRUGS
OptumRX processes prior authorization & exception requests for drugs obtained under the prescription drug benefit (i.e. pharmacy benefit), on behalf of Baylor Scott & White Health Plan, Baylor Scott & White Care Plans and Insurance Company of Baylor Scott & White. To request prior authorization or an exception for a drug that will be obtained under the PHARMACY benefit, submit the request to OptumRx.
MEDICAL BENEFIT DRUGS
Prior authorization requests for drugs obtained under the MEDICAL benefit are not processed by OptumRx. 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.
Appeal requests
PHARMACY BENEFIT DRUGS
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.
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: Prior authorization, exception & appeal requests — submission details
To request coverage for a drug that will be obtained under the Pharmacy Benefit, refer to detail 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.
Initial / Renewal request
ONLINE (OptumRx)
Members*
Providers
FAX
- Individual and Group plans: 844.403.1029 (OptumRx)
- Medicare Part D plan: 844.403.1028 (OptumRx)
PHONE
MAIL
OptumRx
Attn: Prior Auth Exceptions
P.O. Box 25183
Santa Ana, CA 92799
*Log into the member portal through the link. Once logged in, click on “Insurance & Billing” gt; “Baylor Scott & White Health Plan” > “Plan Benefits” > and click ldquo;View” Pharmacy Claims. When on the OptumRx website, you can submit a prior authorization request online.
Appeals (Redeterminations)
FAX
- Individual and Group plans: 877.239.4565 (OptumRx)
- Medicare Part D plan: 877.239.4565 (OptumRx)
PHONE
MAIL
OptumRx
Prior Authorization Department
c/o Appeals Coordinator
P.O. Box 25184
Santa Ana, CA 92799
**Standard Medicare Part D redetermination (appeal) requests must be submitted in writing and cannot be initiated via phone. If you believe waiting 7 days for a standard Medicare Part D redetermination decision could seriously harm the member's life, health or ability to regain maximum function, you can ask for an expedited decision; expedited Medicare Part D redetermination requests can be initiated via phone.
Drug coverage requests
MEDICAL BENEFIT DRUGS
For information regarding prior authorization 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 and allows you to track the status of your request. 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 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.
If submitting drug coverage requests by mail or fax, use the forms below.
Commercial Large Group & Self-Funded Plans The formularies applicable to these plans are developed and maintained by the BSWHP Pharmacy & Therapeutics (P&T) Committee. The utilization management programs (PA requirements, step therapy requirements, quantity limits, etc.), applicable to these formularies are also managed by the BSWHP P&T Committee. Drug coverage request forms for these plans are below.
Drug coverage request forms:
Individual and Small Group Plans
The Essential Health Benefits formulary and applicable utilization management programs (PA requirements, step therapy requirements, quantity limits, etc.) are developed and maintained by OptumRx. Providers can visit the links below for more information regarding OptumRx's prior authorization (PA) procedures and guidelines and to access electronic PA (ePA) portals or drug coverage request forms.
Drug coverage request forms:
Medicare
The Medicare Part D formulary and applicable utilization management programs (PA requirements, step therapy requirements, quantity limits, etc.) are developed and maintained by OptumRx. Providers can visit the links below to access drug coverage request forms and coverage criteria.
Drug coverage request forms:
General forms:
Coverage criteria:
Summary of Utilization Management (UM) Program changes
Individual and small group plans
For members utilizing the Essential Health Benefits formulary, visit this page 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.
Commercial plans
For members utilizing the Group Value or Group Choice formularies, view the most recent document for a summary of utilization management program changes (e.g. new or revised PA criteria and the effective date):
This document is published monthly
Annual PA Approval and Denial Rates
Pharmacy Benefit Prior Authorization Data (Commercial fully insured, individual and small group plans)
Texas House Bill 3459
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.