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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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View member information. Track claims. Get marketing materials and more.

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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.

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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

Medicaid Plan Pharmacy Locations

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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.

Quantity Limits

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.

Medicare Plan 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

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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


Initial / Renewal PA request

ONLINE (OptumRx)

Members*
Providers

FAX

  • Commercial plans: 1-844-403-1029 (OptumRx)
  • Medicare Part D plan: 1-844-403-1028 (OptumRx)

PHONE

  • Commercial plan: 1-855-205-9182 (OptumRx)
  • Medicare Part D plan: 1-844-230-9357 (OptumRx)

MAIL

  • OptumRx
  • Attn: Prior Auth Exceptions
  • P.O. Box 25183
  • Santa Ana, CA 92799
Appeals (Redeterminations)

FAX

  • Commercial plan: 1-877-239-4565 (OptumRx)
  • Medicare Part D plan: 1-877-239-4565 (OptumRx)

PHONE

  • Commercial: 1-888-403-3398 (OptumRx)
  • Medicare Part D plan: 1-888-403-3398 (OptumRx)**

MAIL

  • OptumRx
  • Prior Authorization Department
  • c/o Appeals Coordinator
  • P.O. Box 25184
  • Santa Ana, CA 92799

*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.

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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:
  • 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.
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
Annual PA Approval and Denial Rates
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