St. Lukes Hospital Pharmacy Benefit Frequently Asked Questions - Pharmacy Benefit FAQs

Sep 17, 2026

Upload by Mabel

Frequently Asked Questions explains how Capital Rx administers a prescription pharmacy benefit plan for St. Lukes Hospital members. It covers what a pharmacy benefit manager (PBM) does, how to contact Capital Rx, and how to use the member portal and mobile app. The FAQ also details coverage tools such as formulary lookup, prior authorization (PA), step therapy (ST), and quantity limits (QL), plus guidance on finding expected out-of-pocket costs and obtaining temporary ID cards or reimbursement via the Direct Member Reimbursement (DMR) process.

LanguageEnglish

CategoryForms

FormatPDF

Pages5

Reading Time2 min

AccessFree to download

General Questions

Who is Capital Rx?

What is a Pharmacy Benefit Manager (PBM)?

How do I contact Capital Rx?

Does Capital Rx have an online member portal?

How do I download and log into the Capital Rx mobile app?

Can I use the same pharmacy?

Coverage and Cost Questions

Is my medication covered?

What is a Prior Authorization (PA)?

What is a Step Therapy (ST)?

What is a Quantity Limit (QL)?

How do I know my out-of-pocket cost?

Claims and Pharmacy ID Questions

What if I need to fill a prescription without my physical ID card?

Can I get reimbursed for out-of-pocket pharmacy expenses?

Pharmacy Benefit Frequently Asked Questions Outlined below are some questions and answers to help you better navigate your pharmacy benefit offered to you by Capital Rx, your prescription benefit provider. For additional questions, please contact your dedicated Customer Care team. We are available 24 hours a day, 7 days a week to answer any questions you may have. General Questions Who is Capital Rx? Answer: Capital Rx is an innovative pharmacy benefit manager or PBM. Our role is to oversee your prescription benefit plan. We work hard every day to ensure your prescription drug plan is costeffective but in line with our mission: your health. What is a Pharmacy Benefit Manager (PBM)? Answer: A pharmacy benefit manager (PBM) processes prescription drug claims on behalf of you and your plan sponsor. A plan sponsor is typically an employer, which could be a corporation, government agency, or nonprofit organization. To provide this service, we contract and negotiate with retail pharmacies and pharmaceutical manufacturers to provide the right balance of drug access and costeffectiveness. How do I contact Capital Rx if I have questions? Answer: You can contact Capital Rx by calling the toll-free number that is listed on your ID card. Does Capital Rx have an online member portal? Answer: Yes. You can log in to the member portal by visiting [https://app.cap-rx.com/login](https://app.cap-rx.com/login). How do I download and log into the Capital Rx mobile app? Answer: You can download the Capital Rx mobile app by searching Capital Rx in the app store. To register, visit [https://app.cap-rx.com/register](https://app.cap-rx.com/register or scan)[ or scan](https://app.cap-rx.com/register or scan) the QR code and follow the following steps. 1. Fill in your personal information and click VALIDATE 2. Complete credentials form and click CREATE ACCOUNT 3. Check your email and locate the verification code sent from Capital Rx 4. Enter the code provided to validate your email address With Capital Rx, can I continue to go to the same pharmacy? Answer: Capital Rx maintains a national network of more than 60,000 pharmacies, including national chains and most independent pharmacies. To confirm if your pharmacy is in the network, please login to our member portal and click on ‘Nearby Pharmacies’ to find a pharmacy near you. For any additional questions, please contact your dedicated Customer Care team. Pharmacy Benefit Frequently Asked Questions Is the medication I am currently taking covered by Capital Rx? Answer: To learn if your medication is covered, review your plan’s formulary listing. The formulary will outline the coverage status of a medication and includes if a prior authorization, step therapy, or quantity limit applies. To view the formulary specific to your prescription benefit plan, log into our member portal. Use the navigation menu and select ‘Lookup Formulary’ to learn more about medications that are covered. What is a Prior Authorization (PA)? Answer: Prior authorization means an approval may be required before your pharmacy benefit plan will cover certain drugs. This process ensures you receive a prescription that is safe and is the most cost effective. Once notified by the pharmacy, your doctor will work with Capital Rx to complete paperwork to submit a prior authorization. They can [refer to](refer to www.cap-rx.com/prescribers#prescriber)[ ](refer to www.cap-rx.com/prescribers#prescriber)[www.cap-rx.com/prescribers\#prescriber](refer to www.cap-rx.com/prescribers#prescriber)forms to download a fillable form and more. Most prior authorization reviews are completed within two business days provided that a complete prior authorization request form and all required documentation are correctly submitted. Our clinical team will notify your prescriber in advance of any declinations and assist in expediting you to a preferred alternative therapy. For additional prior authorization question

FAQs

What does Capital Rx do as a pharmacy benefit manager (PBM)?

Capital Rx processes prescription drug claims on behalf of members and the plan sponsor. It contracts and negotiates with retail pharmacies and pharmaceutical manufacturers to balance drug access and cost effectiveness.

How can I check whether my medication is covered?

Review your plan’s formulary listing. Log into the member portal and use the navigation menu to select “Lookup Formulary” to see coverage status and any prior authorization, step therapy, or quantity limit requirements.

What is a prior authorization (PA) and how long does it take?

Prior authorization means approval may be required before the plan covers certain drugs. After your doctor submits a complete request with required documentation, most reviews are completed within two business days.

Sep 17, 2026

Upload by Mabel