Capital Rx

Capital Rx is a next-generation pharmacy benefit administrator that is leading the transformation of pharmacy benefits. It is one of the fastest-growing healthcare companies in America.

Starting Jan. 1, 2025, Capital Rx will administer prescription benefit plans on behalf of Baylor Scott & White Health Plan (BSWHP) for our Commercial Group and Individual/Family plans in addition to Medicare (BSW SeniorCare Advantage and Covenant Health Advantage) plans.

Baylor Scott & White Health Plan will continue to be the Pharmacy Benefit Manager (PBM) while using Capital Rx for Pharmacy Benefit Administrator (PBA) services. BSWHP's expert, Texas-based pharmacy team (with more than 30 years of experience managing pharmacy benefits for all lines of business) will work hand-in-hand with Capital Rx to serve our employers and members in 2025 and beyond.

At Baylor Scott & White Health Plan, we are committed to providing members with an excellent experience. Adding Capital Rx to our pharmacy team will help us do that. We're leveraging Capital Rx's technology with a next-generation platform and member tools to better serve our customers.

Additionally, Capital Rx supports a fully pass-through pricing model based on National Average Drug Acquisition Cost (NADAC) and transparency, moving away from traditional Average Wholesale Price (AWP) based spread pricing. For more information about NADAC and why it's important, see "What is NADAC and why is it important?" below.

The transition to Capital Rx will go into effect Jan. 1, 2025.

Yes. Members with pharmacy coverage through BSWHP will receive a new ID card before Jan. 1, 2025. This card will include both medical and new pharmacy information for processing claims.

Renewals should be submitted to BSWHP by EOB Dec. 20, 2024, to ensure member prescription claims will process in the Capital Rx system on Jan. 1, 2025. Any renewals received after that date will be processed promptly, however we cannot guarantee Capital Rx will have member information loaded in time to process claims on Jan. 1.

BEFORE 1/1/2025

It's business as usual for members who need to fill a prescription now through Dec. 31, 2024. They should have their doctor send their new prescription(s) to their regular pharmacy and present their existing member ID card at the pharmacy to get their medications.

ON OR AFTER 1/1/2025

Members should present their new member ID card at the pharmacy. New ID cards will be mailed in December.

Capital Rx maintains a national network of more than 65,000 retail pharmacies, including national chains and many independent pharmacies. Therefore, members should be able to continue to use their current pharmacy. For additional information or to find a pharmacy, visit our Pharmacy & Drugs page (non-Medicare members) or our Medicare Resources page (Medicare members).

Recurring Mail Order/Specialty: Members who have open (recurring) prescriptions with Optum Home Delivery, Optum Specialty Pharmacy or Baylor Scott & White Specialty Care Team pharmacy do not need to take any action. These pharmacies will remain in our network for mail order and specialty prescriptions. Baylor Scott & White Health Plan and Capital Rx are working closely with these pharmacies to ensure the member's existing profile is updated.

New Mail Order. Members who are prescribed a new mail order medication after Jan. 1, 2025, should ask their doctor to electronically send the prescription to Optum Home Delivery.

If this is the first time the member is using Optum Home Delivery, they will need to create a profile before their prescription can be processed. There are three ways to create a profile:

1. Online: Log into MyBSWHealth.com and select "Pharmacy Benefits" under the Baylor Scott & White Health Plan menu.
   • If you're in the app, this will take you to the Capital Rx member portal.
   • If you're using the desktop version, you'll need to click the "View" button in the yellow bar to access the Capital Rx member portal.
   Once in the Capital Rx portal, select Optum Home Delivery and follow the instructions to register.
2. Phone: Call 833.502.3340 (Medicare members) or 833.502.3339 (non-Medicare members) to reach Optum Home Delivery.
3. Mail: The new prescription mail-in order form can be found at BSWHealthPlan.com/Pharmacy in the "Pharmacy Information and Location" section.

New Specialty: Members who are prescribed a specialty medication after Jan. 1, 2025, should ask their doctor to send the prescription to Optum Specialty Pharmacy. Non-Medicare members also have the option of using Baylor Scott & White Specialty Care Team pharmacy.

Capital Rx maintains a national retail pharmacy network of over 65,000 retail pharmacies, including national chains and many independent pharmacies. Therefore, members should be able to continue using their current pharmacy.

Medicare: There will continue to be preferred retail pharmacies for Medicare members, including Baylor Scott & White pharmacies, HEB, Walmart and Walgreens, along with other pharmacies.

For more details about prescription drug plans or to find in-network pharmacies, visit the Group Pharmacy & Drugs page (non-Medicare members) or the Medicare Resources page (Medicare members) on BSWHealthPlan.com.

You may direct them to this webpage where they can find a Member version of Frequently Asked Questions.

Yes, there will be some formulary changes. To see the 2025 formularies, go to Medicare Resources page (Medicare members) or choose the appropriate link in the Preview my plan section on this web page (non-Medicare members).

Commercial Group and Individual/Family members whose current medication is affected will receive a letter in early November that outlines:

• What the coverage change will be,
• What action to take and
• Preferred lower cost alternatives, if applicable.

For Large Group members, the current, high-quality BSWHP Custom Group Value Formulary will remain in place, ensuring limited disruption, while the new 7-tier formulary option for 2025 will offer more choice and savings with a lower Tier 1 preferred generic copay.

For Medicare members, a one-time transition or temporary fill will be permitted to allow time for members and prescribers to change to a formulary alternative or submit a request for coverage consideration.

Yes. On or after Jan. 1, 2025, coverage requests for pharmacy benefit medications should be directed to Capital Rx. Capital Rx is not able to receive coverage requests before Jan. 1, 2025. Open authorizations will be loaded in Capital Rx's system by Jan. 1 in order to avoid disruption.

Visit our Providers Pharmacy section on or after Jan. 1, 2025, for details about how to submit a coverage request to Capital Rx.

NADAC stands for National Average Drug Acquisition Cost. It is a price index that represents the average price that retail pharmacies pay to purchase outpatient prescription drugs in the United States. Capital Rx has the nation's first Commercial and Medicare NADAC pharmacy network.

Advantages of NADAC:

• Pricing is the same at any pharmacy across the United States
• Published weekly by CMS, available free
• Used for Medicaid reimbursements in 42 states
• Reflects reported prices from more than 600 independent pharmacies and chains
• Reported on an NDC-11 basis for 98.5% of dispensed drugs
• Deflationary over time

Employers/Benefit Administrators - Contact your Client Manager.

Agents - Email Agent Support or call 866.781.7008 and press 5.