Important Forms & Information

Our Formulary

Pharmacy Benefit Information for Members on Individual & Family and Small Group ACA Plans
2020 Essential Health Benefits Formulary
2021 Essential Health Benefits Formulary
Monthly Essential Health Benefits Formulary Changes

Pharmacy Benefit Information for Members on Commercial & Self-Funded Plans
2021 Group Value Formulary
2020 Group Value Formulary
Quantity Limits-Group Value
HDHP Chronic Preventive Medication List
Monthly Group Value Formulary Changes

Benefit Information for Members on Medicare Plans
2021 FirstCare Advantage Dual SNP Formulary
2020 FirstCare Advantage Dual SNP Formulary

Benefit Information for Members on Medicaid CHIP

FirstCare is state mandated to adhere to the Texas Medicaid formulary and Preferred Drug List, which are developed and maintained by the Texas Drug Utilization Review (DUR) Board and Texas HHSC Vendor Drug Program (VDP). Additional information regarding VDP including formularies, preferred drug list, and Texas DUR Board meeting minutes and updates can be found on the Texas Vendor Drug Program webpage. FirstCare administers the prior authorization criteria approved by the Texas DUR Board. For a listing of clinical edits implemented by FirstCare please click here, and for access to FirstCare’s prior authorization forms please click here.

To obtain a pharmacy prior authorization assistance for Medicaid CHIP, please call FirstCare Medicaid CHIP PBM, Navitus, Toll Free at 1-877-908-6023, and select the prescriber option to speak with the Prior Authorization department between 6 a.m. to 6 p.m. Monday through Friday, and 8 a.m. to 12 p.m. Saturday and Sunday Central Time (CT), excluding state approved holidays.

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.
Group Value Preventive Medication List
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. (Not applicable to Medicare plans.)
Specialty Pharmacy Program

Pharmacy Information

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

Pharmacy Benefit Drug Requests — Prior Authorizations, Exceptions & Appeals

*Applies to plans that utilize OptumRx as the pharmacy benefits manager.

Plans that do not utilize OptumRx as the pharmacy benefits manager, can click the links below for information regarding prior authorizations and appeals.

• Medicare
• Medicaid
  • STAR
    • PA Forms
    • Appeals Information
  • CHIP
    • PA Forms
    • Appeals Information

Initial/Renewal Prior Authorization & Exception Requests
OptumRx 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 OptumRx.

Appeal Requests
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.

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 OptumRx. 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      myFirstCare Self-Service   Providers      CoverMyMeds      SureScripts      PreCheck MyScript
FAX	1-844-403-1029
PHONE	1-855-205-9182
MAIL	OptumRx   Attn: Prior Auth Exceptions   P.O. Box 25183   Santa Ana, CA 92799

 

Appeals (Redeterminations)
ONLINE	Utilize links above
FAX	1-877-239-4565
PHONE	1-888-403-3398
MAIL	OptumRx   Prior Authorization Department   c/o Appeals Coordinator   P.O. Box 25184   Santa Ana, CA 92799

Drug Coverage Requests

*Applies to plans that utilize OptumRx as the pharmacy benefits manager.

Medical Benefit Drugs
For information regarding coverage policies and prior authorization submission process for drugs obtained under the medical benefit (e.g. drug to be billed on a medical claim or through “buy and bill”), click here.

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 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 (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. Refer to the table above for links to online portals to submit a drug coverage request electronically.

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 Scott and White Health Plan (SWHP) 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 SWHP P&T Committee.  Drug coverage request forms for these plans are below.
  • Drug coverage request forms:  
    • OptumRx Prior Authorization & Exception Request Form
    • Texas Standard Prescription Drug Prior Authorization Request 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 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:
      • OptumRx Prior Authorization & Exception Request Form
      • Texas Standard Prescription Drug Prior Authorization Request Form 

​​​​​Summary of Utilization Management (UM) Program Changes

• Individual and Small Group Plans 
  • For members utilizing the Essential Health Benefits formulary, click here 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 formularies, click here 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

2019 Pharmacy benefit prior authorization approval and denial rates

• FirstCare Commercial fully insured plans with pharmacy benefit manager OptumRx (Sept 2019 – Dec 2019)
• FirstCare Commercial plans with pharmacy benefit manager Navitus
• FirstCare Individual and Small Group plans