Frequently Asked Questions

CarelonRx is a pharmacy benefit manager (PBM) with a whole-health focus. This means we manage the pharmacy portion of healthcare benefits. Since we were launched by one of the nation’s largest health organizations, we have a deep understanding of both pharmacy and medical insights. This expertise helps us drive better health outcomes, lower costs, and simplify pharmacy experiences.

For help, please call the Pharmacy Member Services number on the back of your member ID card. If you cannot find your ID card or need more specific contact information, please visit the Contact Us page.

Ask your doctor to electronically send (preferred, if available) or fax a new prescription to CarelonRx Pharmacy.

Call the number on your member ID card to request more information.

When your doctor writes your prescription, it may include refills. Refills are additional doses of medicine you can receive after you’ve taken the first doses on schedule. Not all prescriptions need refills to make you feel better. You can refill CarelonRx Pharmacy prescriptions by logging in to your CarelonRx member account and following the on-screen instructions. If your prescription expires, you won’t be able to refill it until your doctor renews the prescription. If you have questions, please call the member services phone number on the back of your ID card.

Also known as a “formulary,” this is a list of prescription drugs your plan covers, including brand names and generics approved by the U.S. Food & Drug Administration (FDA). We sort our drug lists into tiers, which determine your share of a drug’s cost. The lower the tier, the lower your share of the cost. These decisions are based on: 

• How well a drug works to improve health.
  
• Whether there are over-the-counter options available.
  
• A drug’s cost compared to other drugs used for the same type of treatment.

If you want to take a drug that’s not on the drug list, you may have to pay its full cost. You can also talk to your doctor or pharmacist to see if there’s a different drug covered by your plan that will work just as well. Generic or over-the-counter options may also be available. Only you and your doctor can decide what drugs are right for you.

You or your doctor can request a drug not on your drug list based on medical necessity. Your doctor can seek preapproval or prior authorization by following the instructions on this page. You can also call the pharmacy member services number on the back of your ID card. If the request is approved, the amount you pay for the drug will depend on your plan’s benefit.

General information on how we make decisions can be found on our How We Evaluate Care page. Information on specific programs, including prior authorization requests and formulary management, can be found on our Providers page.

A brand name drug is FDA approved and usually available from only one company. It may be protected by a patent, which means it can only be made or sold by the company that has the patent.

A generic drug is also FDA approved. It has the same active ingredients and effects as the brand name drug. A generic drug is usually available only after the patent on the brand-name drug expires. Generics are just as effective as originals and are usually less expensive than brand name drugs.

Some rare, complex, or chronic conditions such as cancer, rheumatoid arthritis, or multiple sclerosis (MS) need specialty medications. These drugs are often injected or infused, and they may need to be stored or delivered in specific ways. Specialty medications typically have a higher cost.

Once you log in to your CarelonRx member account, you can view a summary of your pharmacy benefit, including drug-specific pricing and coverage information and a list of in-network retail pharmacies. You can call us at the Pharmacy Member Services number on the back of your ID card to speak with a CarelonRx member services representative, 24/7.

Once you log in to your CarelonRx member account, select “Price a Medication” from the menu, enter the drug name, and follow the instructions to view cost and coverage information for your prescription. You can also call the Pharmacy Member Services number on the back of your ID card to speak with a CarelonRx member services representative, 24/7.

Once you log in to your CarelonRx member account, select “Find a Pharmacy,” enter the zip code or city name you want to search, and follow the instructions to find a participating retail pharmacy. You can also call us at the Pharmacy Member Services number on the back of your ID card to speak with a CarelonRx member services representative, 24/7.

If you are having trouble finding an in-network pharmacy that can fill your prescription, you can call us at the Pharmacy Member Services number on the back of your ID card to speak with a CarelonRx member services representative 24/7.

Once you log in to your CarelonRx member account, select “Access Your ID Card” from the menu and choose your preferred delivery method for your replacement ID card. To download commonly used forms, select “Support” from the top navigation and navigate to “Forms.” There you will find a list of commonly used forms. You can call the Member Services number on the back of your ID card to speak with a representative, 24/7. Alternatively, your pharmacist can call the CarelonRx Pharmacy Help Desk.

If your medication has been lost/damaged, or if you are travelling and need to refill your prescription early, please contact our Member Services team at the pharmacy services number on the back of your ID card to determine whether an override of your benefit allowances is available.

Reporting possible errors helps ensure that you are getting the full value of your pharmacy benefit and allows us to detect other problems. If you suspect an error, you can call us at the pharmacy member services number on the back of your ID card to speak with a CarelonRx member services representative, 24/7.