Drug Lists & Benefit Forms

FirstCare Prescription Drug Lists

Select from one of the links below to view your plan’s drug formulary (list of approved drugs), list of medications requiring prior authorization, and medications requiring step therapy.

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  2019 Commercial & Self-Funded Prescription Drug Formulary (5-Tier)

  Effective 1/1/2019; includes details on prior authorizations, step therapy & quantity limits
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  2019 ACA Small Group Prescription Drug Formulary (5-Tier)

  Effective 1/1/2019; includes details on prior authorizations, step therapy & quantity limits
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  2019 Commercial Prescription Drug Formulary (4-Tier)

  Effective 1/1/2019; includes details on prior authorizations, step therapy & quantity limits
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  Formulary Updates 
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  Medications available through mail order

FirstCare Prescription Drug Benefit Forms

You can access our prescription drug benefit forms for reimbursements, home delivery service, or to request prior authorization for a prescription medication by clicking on the document links below:

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  Novixus Mail Order Form

  Please register on Novixus.com

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  Drug Claim Reimbursement Form

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  Exception Request Form

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  Appeals Request Form

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  Texas Standard Prescription Drug Prior Authorization Request Form

If you have any questions, contact a FirstCare representative or Ask the Pharmacist for more information.