Pharmacy Resources

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.

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:

• Prior Authorization Request Form
• Texas Standard Prior Authorization Form

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.

• PA Procedures and Guidelines (OptumRx)

Drug coverage request forms:

• Prior Authorization Request Form
• Texas Standard Prior Authorization Form

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:

• Drug coverage request forms (OptumRx)

General forms:

• Medicare Coverage Determination Request Form (updated 4/28/2022)
• Medicare Redetermination Request Form

Coverage criteria:

• Prior Authorization Criteria
• Step Therapy 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):

• June 2022
• May No. 2 2022
• May 2022
• April 2022
• March 2022 Addendum No. 2
• March 2022 Addendum
• March 2022
• February 2022 Addendum
• February 2022
• January 2022

This document is published monthly

Annual PA Approval and Denial Rates

Pharmacy Benefit Prior Authorization Data (Commercial fully insured, individual and small group plans)