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 Scott and White Health Plan, Scott and White Care Plans, and Insurance Company of Scott and 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 (i.e. drug will be billed on a medical claim by a provider), submit the request to
SWHP 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
Commercial plans: Appeal requests for drugs obtained under the PHARMACY benefit are processed by SWHP (not OptumRx). To request a drug coverage appeal for a PHARMACY benefit drug, submit the request to SWHP.
Medicare Part D plans: OptumRx processes appeal (redetermination) requests for Medicare Part D drugs. To request a drug coverage appeal for a Part D drug, submit the request to OptumRx.
NOTE: Medicare Part B appeals are processed by SWHP (not 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.
Drug Prior Authorization, Exception, & Appeal Requests — Submission Details
For information regarding how to submit a drug coverage request, refer to the table below.
Table — Drug Prior Authorization, Exception, & Appeal Requests — Submission Details
Pharmacy Benefit Drug | Medical Benefit Drug (i.e. drug to be billed on a medical claim — "buy and bill") |
| Initial / Renewal PA request |
ONLINE (OptumRx) Members* Providers | ONLINE (SWHP) Providers |
FAX | FAX |
PHONE - Commercial plan: 1-855-205-9182 (OptumRx)
- Medicare Part D plan: 1-844-230-9357 (OptumRx)
| PHONE |
MAIL - OptumRx
- Attn: Prior Auth Exceptions
- P.O. Box 25183
- Santa Ana, CA 92799
|
| Appeals (Redeterminations) |
FAX - Commercial plan: 1-254-298-3663 (SWHP)
- Medicare Part D plan: 1-877-239-4565 (OptumRx)
| FAX |
PHONE - Commercial plan: 1-800-321-7947 (SWHP)
- Medicare Part D plan: 1-888-403-3398 (OptumRx)**
| PHONE |
MAIL Commercial plan: - SWHP
- c/o Appeals and Grievances
- 1206 West Campus Drive
- Temple, TX 76502
Medicare Part D plan: - OptumRx
- Prior Authorization Department
- c/o Appeals Coordinator
- P.O. Box 25184
- Santa Ana, CA 92799
| MAIL - SWHP
- c/o Appeals and Grievances
- 1206 West Campus Drive
- Temple, TX 76502
|
*Log into the SWHP member portal through the link. Once logged in, click on the Pharmacy Claims link. When on the OptumRx website, you can submit a prior authorization request online.
**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 Request Forms
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. PHARMACY benefit drug coverage request forms can be found below.
Providers:
Commercial members:
Medicare plans: