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

Pharmacy Locations

Network Locations

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

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.

• 2021 SWHP Group Value Formulary
• 2021 SWHP Group Choice Formulary
• 2021 Federal Employees Benefit Plan Group Value Formulary
• 2021 BSWH Employee Group Value Formulary
• 2021 Essential Health Benefits Formulary
• Texas Medicaid Vendor Drug Program Online Formulary

Quantity Limits

• Quantity Limits-Group Value and Group Choice

Preventive Care Medications

Under the Affordable Care Act, also known as the health care reform law, SWHP 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 filled at a network pharmacy to be covered at no cost share.

• SWHP Group Value and Choice Preventive Medication List
• SWHP Essential Health Benefits Preventive Medication List

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 Formulary Changes

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

Monthly Group Value and Group Choice Formulary Changes

Monthly Essential Health Benefits Formulary Changes

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 (e.g., 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

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.

MEDICAL BENEFIT DRUGS

For information regarding prior authorization and appeal submission process for drugs obtained under the MEDICAL benefit, refer to Medical Authorization Requests.

Pharmacy Benefit 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 — Pharmacy Benefit Drug Prior Authorization, Exception, & Appeal Requests — Submission Details

^*Log into the member portal through the link. Once logged in, click on “Insurance & Billing” > “Scott & White Health Plan” > “Plan Benefits” > and click “View” Pharmacy Claims. 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 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 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 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:
• Prior Authorization Request Form
• Texas Standard Prior Authorization 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 prior authorization (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:
  • Prior Authorization Request Form
  • Texas Standard Prior Authorization Form
• Medicare

  The Medicare Part D 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 to access drug coverage request forms and coverage criteria.

  • Drug coverage request forms:
    • Drug specific forms (OptumRx)
    • General forms:
    • Medicare Coverage Determination Request Form
    • Medicare Redetermination Request Form
  • Coverage criteria:
    • Prior Authorization Criteria
    • Step Therapy Criteria

Summary of Utilization Management (UM) Program Changes

• Individual and small group plans

  For members utilizing the Essential Health Benefits formulary, visit this page 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 or Group Choice formularies, view the most recent document for a summary of utilization management program changes (e.g. new or revised PA criteria and the effective date):

  • October 2021
  • September 2021 Second Addendum
  • September 2021 Addendum
  • September 2021
  • August 2021
  • July 2021
  • June 2021 Addendum
  • June 2021
  • May 2021

  This document is published monthly

Annual PA Approval and Denial Rates

Pharmacy Benefit Prior Authorization Data (Commercial fully insured, individual, and small group plans)