Drug Requests — Prior Authorizations, Exceptions & Appeals
Initial/Renewal prior authorization & exception requests
PHARMACY BENEFIT DRUGS
Optum Rx processes prior authorization & exception requests for drugs obtained under the prescription drug benefit (i.e. pharmacy benefit), on behalf of Baylor Scott & White Health Plan, Baylor Scott & White Care Plans and Insurance Company of Baylor Scott & White. To request prior authorization or an exception for a drug that will be obtained under the PHARMACY benefit, submit the request to Optum Rx.
Medicare coverage of continuous glucose monitors (CGMs), diabetic test strips and blood glucose meters
To submit a coverage request (organization determination) to obtain CGMs, diabetic test strips or blood glucose meters from a pharmacy, submit the request to Optum Rx using the contact information below. Not all diabetic test strips or glucose meters require an organization determination; non-preferred products and products exceeding certain quantities require an organization determination for coverage. Refer to the Evidence of Coverage (EOC) document for details.
MEDICAL BENEFIT DRUGS
Prior authorization requests for drugs obtained under the MEDICAL benefit are not processed by Optum Rx. 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 BSWHP 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 Optum Rx. To request a drug coverage appeal for a PHARMACY benefit drug, submit the request to Optum Rx.
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 drugs: Prior authorization, exception & appeal requests — submission details
To request coverage for a drug that will be obtained under the Pharmacy Benefit, refer to detail 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.
Initial / Renewal request
ONLINE (Optum Rx)
Members*
*Click "View" Pharmacy Claims. When on the Optum Rx website, you can submit a prior authorization request online.
Providers
FAX
- Individual and Group plans: 844.403.1029 (Optum Rx)
- Medicare Part D plan: 844.403.1028 (Optum Rx)
PHONE
MAIL
Optum Rx Prior Authorization
P.O. Box 2975
Mission, KS 66201
Appeals (Redeterminations)
FAX
- Individual and Group plans: 877.239.4565 (Optum Rx)
- Medicare Part D plan: 877.239.4565 (Optum Rx)
PHONE
MAIL
Optum Rx Prior Authorization Appeals
P.O. Box 2975
Mission, KS 66201
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 detail 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 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.
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 BSWHP 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 BSWHP P&T Committee. Drug coverage request forms for these plans are below.
Drug coverage request forms:
2025 Coverage criteria:
2024 Coverage criteria (Updated 11/1/24):
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 Optum Rx. Providers can visit the links below for more information regarding Optum Rx's prior authorization (PA) procedures and guidelines and to access electronic PA (ePA) portals or drug coverage request forms.
Drug coverage request forms:
2025 Coverage criteria:
2024 Coverage criteria (Updated 11/1/2024):
Medicare
The Medicare Part D formulary and applicable utilization management programs (PA requirements, step therapy requirements, quantity limits, etc.) are developed and maintained by Optum Rx. Providers can visit the links below to access drug coverage request forms and coverage criteria.
Drug coverage request forms:
General forms (Updated 11/6/2023):
Coverage criteria (Updated 11/1/24):
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):
This document is published monthly
Annual PA Approval and Denial Rates
Pharmacy Benefit Prior Authorization Data (Commercial fully insured group and individual plans)
Texas House Bill 3459
If you are a provider and have questions about prior authorization exemptions or gold-card status related to Texas House Bill 3459 for requests submitted to Optum Rx, visit txgoldcardfaq.com or call Optum Rx at 855.205.9182. Notices about gold-card status for requests submitted to Optum Rx are sent by Optum Rx to providers via mail. Call Optum Rx at 855.205.9182 to update your preferred method of contact or to update your contact information for gold-card status communications.