What does CarelonRx do?

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.

How do I contact CarelonRx?

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.

How can I send my prescription to CarelonRx?

There are several ways you can request a new prescription through our home delivery or specialty pharmacies:

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

  2. Log in to our CarelonRx member portal, click “Support,” followed by “Forms,” and follow the instruction on-screen.

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

How do I refill my prescription?

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 Mail 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.

How do I pay my bill?

To pay for your home delivery or specialty pharmacy prescriptions, please log in to our CarelonRx member portal or call the member services number on your ID card. You can pay by check, money order, electronic check, credit card, or debit card. We take VISA®, Discover®, MasterCard®, and American Express®. If you use a paper home delivery order form, please remember to include your credit/debit card number and expiration date in the space provided.

What is a drug list?

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.
What if the medicine my doctor prescribes is not on the drug list?

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.

How does CarelonRx make decisions about which prescription drugs require prior authorization?

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.

What is the difference between brand name and generic drugs?

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.

What are specialty medications?

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.

Where can I find more details about my CarelonRx pharmacy benefit?

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.

How can I find drug-specific cost and coverage information?

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.

How can I find a pharmacy that will accept my prescription coverage?

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.

Where can I download forms or a new member ID card?

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 I need an emergency supply of my medication, who do I contact for an exception?

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.

What can I do if I think there was an error in the application of my pharmacy benefit?

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.

Who do I contact if I am having trouble filling a prescription or using my pharmacy benefit?

If you are having trouble filling a prescription or using your pharmacy benefit, you can call us at the Member Services number on the back of your ID card to speak with a CarelonRx member services representative, 24/7.

If you have been prescribed a drug that is not covered, you or your doctor can request a drug not on your drug list based on medical necessity. To get the process started, call the Pharmacy Member Services number on the back of your member ID card or by downloading and submitting a request form from our website. If the request is approved, the amount you pay for the drug will depend on your plan’s benefits.