Provider Pharmacy Resources

Jump to Page Topics

• Pharmacy Locations: Directories and Locator Tool
• Prescription Drug Lists/Formularies
• Drug Requests — Prior Authorizations, Exceptions and Appeals
• Medication Prior Authorization Forms
• Medication Redetermination Request Forms

IMPORTANT NOTICE: For BSWH Employee Plan ONLY.

All SWHP non-contracted provider requests for prior authorization of services or drugs obtained through the medical benefit are processed by Cigna. 

Please take the following steps to ensure your request is processed in a timely manner:

• You MUST FIRST verify benefits and eligibility with SWHP by phone. Call 1-844-769-3994 and speak to a customer advocate.
• When verification is complete, you may have the advocate transfer you directly to Cigna, OR you may contact Cigna at 1-866-494-4872 to determine prior authorization requirements and initiate prior authorization requests.

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Our mission is to assist prescribers and you in selecting cost-effective drug therapies and providing the highest quality medications to our Scott and White Health Plan patients. To accomplish this goal, an extensive collaborative effort between pharmacy and the medical staff is required.

Pharmacy Locations

Network Locations

Find network pharmacies by using the Provider Directory and Pharmacy Locator. (Not applicable to Medicare, see Medicare Directory below.)

Baylor, Scott & White Pharmacy Locations

For information regarding Baylor Scott & White Pharmacies, visit Baylor Scott & White Pharmacies online to refill prescriptions, transfer pharmacies and find medication information.

Medicare Plan Pharmacy Locations

• SeniorCare Advantage Pharmacy Directory

Medicaid Plan Pharmacy Locations

• RightCare STAR Medicaid Pharmacy Locations

Prescription Drug Formularies

Our formulary is the guide for prescription coverage for all Scott and White Health Plan patients. Please refer to this formulary when prescribing for your SWHP patients. The formulary is not a substitute for the professional and clinical judgment of the physician.

• SWHP Group Value Formulary
• SWHP Group Choice Formulary
• Federal Employees Benefit Plan Group Value Formulary
• ERS Group Value Formulary
• McLennan County Group Value Formulary
• BSWH Employee Group Value Formulary
• Essential Health Benefits Formulary
• Texas Medicaid Vendor Drug Program Online Formulary

Medicare Plan Formulary

• Medicare Formulary

SWHP Specialty Pharmacy Drug Program

The SWHP Specialty Pharmacy Program offers the choice of two specialty care pharmacies to help manage and access specialty drugs. (Not applicable to Medicare plans.)

Request an addition to the SWHP Drug List

Complete the Formulary Addition Request Form to request a prescription drug be added to our formulary.

SWHP upcoming Prescription Drug List changes

Download the SWHP Formulary Updates from the Pharmacy & Therapeutics Committee.

SWHP Group Value Formulary Updates

Essential Health Benefits Formulary Updates

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.

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.

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* SWHP Member Portal Providers CoverMyMeds SureScripts PreCheck MyScript	ONLINE (SWHP) Providers SWHP Provider Portal
FAX Commercial plans: 1-844-403-1029 (OptumRx) Medicare Part D plan: 1-844-403-1028 (OptumRx)	FAX 1-800-626-3042 (SWHP)
PHONE Commercial plan: 1-855-205-9182 (OptumRx) Medicare Part D plan: 1-844-230-9357 (OptumRx)	PHONE 1-800-321-7947 (SWHP)
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 1-254-298-3663 (SWHP)
PHONE Commercial plan: 1-800-321-7947 (SWHP) Medicare Part D plan: 1-888-403-3398 (OptumRx)**	PHONE 1-800-321-7947 (SWHP)
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.

• • 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: General drug coverage request forms can be found below. These forms can be used to submit a request by mail or fax. o Providers: Using the electronic portals above is the most convenient way to submit and track the status of requests. However, if you choose to submit drug coverage requests by mail or fax, visit the Provider Portal to obtain drug request forms.
• • Phone requests: Drug coverage requests can be initiated by phone. Call the applicable phone number listed in the table above to initiate a request.

Providers:

• SWHP Provider Portal

Commercial members:

• Prior Authorization Request Form
• Texas Standard Prior Authorization Form

Medicare members:

• Request for Medicare Prescription Drug Coverage Determination
• Medicare Redetermination Request Form
• Prior Authorization Criteria
• Step Therapy Criteria