ALL of the following

• Drug is listed on the Baylor Scott & White Health Plan formulary (Drug List) current as of the effective date and has not been removed from the market.
• Prescription is filled at a Baylor Scott & White Health Plan network pharmacy, or other pharmacy arrangements allowed by the plan (e.g., mail-order) are followed as specified in the Evidence of Coverage.
• Other plan rules are followed, including prior authorization, quantity limits, step therapy requirements, and formulary tier cost‑sharing rules when applicable.
• Drug is determined to be medically necessary for the member by the prescriber and documentation supports the clinical indication.

ALL of the following

• Prior Authorization

  • Prior authorization is required for drugs that the plan has designated as PA — prescriber must obtain approval before the drug will be covered; absence of approval may result in denial of coverage.
  • PA criteria will specify required clinical information, trials of preferred therapies when applicable, and duration of approval; prescribers should follow the plan’s prior authorization submission instructions.

• Quantity Limits

  • Quantity limits (QL) restrict the amount of drug the plan will cover for a given time period (e.g., tablets per 30 days).
  • QLs may apply in addition to standard one‑month or three‑month supply rules and are enforced at the pharmacy; examples (illustrative) include limits like 60 tablets/30 days for certain strengths of a medication.

• Step Therapy

  • Step therapy (ST) requires trial and failure, intolerance, or contraindication of specified step agents before a non‑preferred agent will be covered.
  • Documentation of prior trials and outcomes is required for coverage of higher‑tier or non‑preferred agents when ST is applicable.
• The plan’s utilization controls and clinical criteria are published in the formulary and related documents; providers and members may request exceptions if clinically appropriate.

ALL of the following

• New members transitioning to the plan may receive temporary (transition) supplies for drugs they are currently taking even if the drug is not on the formulary or is subject to new restrictions; transition fill availability and duration follow plan procedures.
• When a formulary change affects a member, the plan will provide a 30‑day notice or allow a one‑time 30‑day refill at a network pharmacy when the member requests a refill, as required by Medicare rules.
• Long‑term care (LTC) emergency supplies and other short‑term fills are available per plan policies (e.g., a 31‑day emergency supply for LTC residents) consistent with state and CMS requirements.
• Members and prescribers should contact Customer Service or follow the Evidence of Coverage to initiate transition fills or request assistance during a coverage change.