Drug Requests — Prior Authorizations, Exceptions & Appeals
Initial/Renewal Prior Authorization & Exception Requests
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 and 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 to the rightbelow. 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.
Initial/Renewal Request
Online
Phone
Fax
Mail
Capital Rx
Attn: Prior Authorization Dept.
9450 SW Gemini Drive, No. 87234
Beaverton, OR 97008
Appeal 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.
Appeals (Redeterminations)
Online
Phone
Fax
Mail
Capital Rx
Attn: Appeals Dept.
9450 SW Gemini Drive, No. 87234
Beaverton, OR 97008
Pharmacy Benefit Drugs: Prior Authorization, Exception & Appeal Requests — Submission Details
To request coverage for a drug that will be obtained under the Pharmacy Benefit, use the contact information above.
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. 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. Refer to detail above for links to ePA portal and electronic forms.
If submitting drug coverage requests by mail or fax, use the forms below.
Commercial Large Group & Self-Funded Plans
Drug coverage request forms:
2025 Coverage criteria:
Individual and Small Group Plans
Drug coverage request forms:
2025 Coverage criteria:
Medicare
General forms (Updated 1/1/2025):
Spanish forms (Updated 1/1/2025):
2025 Coverage criteria:
Annual PA Approval and Denial Rates
Pharmacy Benefit Prior Authorization Data (Commercial fully insured group and individual 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 Capital Rx, visit Capital Rx Gold-Card - FAQ - 2024. To update your preferred method of contact or contact information for gold-card status communications from Capital Rx, contact Capital Rx at TXGoldCardSupport@cap-rx.com.