Pharmacy FAQ

Please call our CapitalRx Customer Service team at (888) 227-7940 (TTY 711). Hours of operation are 24 hours a day/7 days a week/365 days a year.

CapitalRx is a pharmacy benefit manager (PBM). A PBM primarily provides the pharmacy claims processing platform and supports administrative services for the pharmacy portion of health care benefits. CapitalRx will work with Memorial Hermann Health Plan and network pharmacies to provide cost-effective prescription drug benefits for Memorial Hermann Health Plan members and to improve member health and minimize their out-of-pocket costs.

A pharmacy benefit manager (PBM) processes and pays prescription drug claims for its members. It contracts with pharmacies and builds and maintains drug formularies. A PBM also negotiates discounts and rebates with drug manufacturers.

CapitalRx is our pharmacy benefit manager and manages the pharmacy benefits on behalf of Memorial Hermann Health Plan and its members.

Members can call our Customer Service line to ask specific questions on pharmacies and prescriptions that they are taking. You can find more information on network pharmacies by clicking here.

Memorial Hermann Specialty Pharmacy and Costco Specialty Pharmacy are just two specialty pharmacy vendors that Memorial Hermann Health Plan is using. Members can use any in-network specialty pharmacy vendor of their choice. Please search for a pharmacy using our tool here.

Look in the Pharmacy Locator on CapitalRx’s website or call Customer Service at (888) 227-7940 (TTY 711) for additional information. Hours of operation are 24 hours a day/7 days a week/365 days a year. 

They can call CapitalRx's Customer Service at (888) 227-7940 (TTY 711) for additional information. Hours of operation are 24 hours a day/7 days a week/365 days a year. 

All ID cards will be sent out prior to Jan. 1, 2025. If you don’t receive an ID card by then, please call CapitalRx's Customer Service at (888) 227-7940 (TTY 711) for additional information. Hours of operation are 24 hours a day/7 days a week/365 days a year. You may also call Memorial Hermann Health Plan directly by calling (855) 645-8448 to request a ID card to be reprinted or mailed.

No, any current prior authorizations that are approved for current members will remain in place for the length of the approval period. New members to the plan may need to request a new coverage determination.

No, any current approved exceptions will remain in place for the length of the approval period.

Yes, the formulary may change each month. We encourage members to check the new formulary online for the latest information or call CapitalRx Customer Service at (888) 227-7940 (TTY 711) for additional information. Hours of operation are 24 hours a day/7 days a week/365 days a year.

To find out or search if your prescription drug is covered, please see the comprehensive formulary on our webpage.

Yes, there are tiers and certain medications for diabetes, blood pressure, and cholesterol are available at no cost to you. Please check the formulary online or call CapitalRx Customer Service at (888) 227-7940 (TTY 711) for additional information.

Depending on your medication, a 90-day medication refill may provide additional savings for you. Please check with your doctor to see if a 90-day prescription is appropriate for you.

There is no Coverage Gap, also known as the “Donut Hole”

The annual out-of-pocket cap for prescription drugs is reduced to $2,000. This means that no matter how much your medicines cost, you will never have to pay more than $2,000 a year.

Memorial Hermann Health plan works with Outcomes to provide Medication Therapy Management (MTM) services to our members. This service is absolutely FREE for our members and enables them to improve their health, optimize their medications, and address any concerns with a pharmacist.

Medication Therapy Management (MTM) is a free program offered by Medicare Part D plans to certain members to help improve their medication use so they can better manage their chronic conditions (e.g., diabetes, high blood pressure, Chronic Heart Failure, End-Stage Renal Disease, Alzheimer’s disease, Bone disease-arthritis (including osteoporosis, osteoarthritis, and rheumatoid arthritis), Human immunodeficiency virus /acquired immunodeficiency syndrome (HIV/AIDS), Mental health (including depression, schizophrenia, bipolar disorder, and chronic/disabling mental health conditions), Respiratory disease (including asthma, chronic obstructive pulmonary disease (COPD), and chronic lung disorders) and high cholesterol) and improve their overall health.

Read more about our MTM program here.

You can call Outcomes Patient Engagement Team directly via phone toll free at (855) 905-4689. The hours of operation is from Monday-Friday, 8 a.m. to 6 p.m. Central Time.

Yes, you can call Outcomes Patient Engagement Team at (855) 905-4689 (TTY 711) and request to opt out of the program.

For more information on our MTM program please click here.

Yes, we are here to help. Please call the Customer Service department phone number at (888) 227-7940. The hours of operation are 24 hours a day/7 days a week/365 days a year. You may also call Outcomes Patient Engagement team directly for MTM related questions at (855) 905-4689 (TTY 711). The hours of operation are from Monday-Friday, 8 a.m. to 6 p.m. Central Time.

Costco Mail Order Pharmacy services is the Mail Order Pharmacy for Capital Rx and Memorial Hermann Health Plan. Members will need to setup a new account online or call Costco Customer Service. It is easy to begin using Costco Mail Order Pharmacy. You can register online by clicking here. You do not need to be a Costco Wholesale member to use Costco Mail Order Pharmacy.

Memorial Hermann Health Plan and CapitalRx have partnered with Costco Mail Order Pharmacy to provide your mail order prescription benefits. Members can also use any in-network pharmacy vendor of their choice.

No. You don't need to be a Costco Member to use Costco pharmacies, including Costco Mail Order Pharmacy.

Yes, please reach out to Costco Mail Order Pharmacy, they allow members to enroll in the automatic refill program. Please be aware that prescriptions on auto-refill will still require your consent before we can fill them. A valid email address and payment method must be on file with Costco Mail Order Pharmacy in order to use the auto-refill system. To enroll your prescription in the auto-refill program, you can either enable auto-refill for each prescription yourself on the Refill Prescriptions page on the online Costco Mail Order Pharmacy account, or Contact Costco Mail Order Pharmacy via phone at (800) 607-6861. Please note auto-refills will not be available for controlled substances and refrigerated medications.

You can use the prescription number and warehouse number to order your prescription through the Costco website or by calling their Customer Service. You can find this information on every prescription label you get from Costco.

Memorial Hermann Health Plan and CapitalRx have partnered with Costco Mail Order Pharmacy to provide your mail order prescription benefits. Members can also use any in-network pharmacy vendor of their choice.

Coming soon.

The Medicare Prescription Payment Plan is a new payment option in the prescription drug law that works with your current drug coverage to help you manage your out of-pocket Medicare Part D drug costs by spreading them across the calendar year (January-December). Starting in 2025, anyone with a Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage Plan with drug coverage) can use this payment option. All plans offer this payment option and participation is voluntary. If you select this payment option, each month you’ll continue to pay your plan premium (if you have one), and you’ll get a bill from your health or drug plan to pay for your prescription drugs (instead of paying the pharmacy). There’s no cost to participate in the Medicare Prescription Payment Plan.

You’re most likely to benefit from participating in the Medicare Prescription Payment Plan if you have high drug costs earlier in the calendar year. Although you can start participating in this payment option at any time in the year, starting earlier in the year (like before September), gives you more months to spread out your drug costs. Go to Medicare to answer a few questions, and find out if you’re likely to benefit from this payment option.

You may call our CapitalRx Customer Service number at (888) 227-7940 or write to us to participate in this payment option at any time during the plan year.

When you fill a prescription for a drug covered by Part D, you won’t pay your pharmacy (including mail-order and specialty pharmacies). Instead, you’ll get a bill each month from your plan. Your monthly bill is based on what you owe for any prescriptions you get, plus your previous month’s balance, divided by the number of months left in the year.

Note: Your payments might change every month, so you might not know what your exact bill will be ahead of time. Future payments might increase when you fill a new prescription or refill an existing prescription because as new out-of-pocket drug costs are added into your monthly payment, there are fewer months left in the year to spread out your payments.

Yes. Like any other debt, you’re required to pay the amount you owe. As long as you continue to pay your plan premium (if you have one), you’ll still have drug coverage through Memorial Hermann Advantage. If you withdrawal from the Prescription Payment Plan or are withdrawn, but still owe a balance, you’re required to pay the amount you owe, even if you’re no longer participating in this payment option.

You may make payments for any outstanding payments or for your normal scheduled monthly payments through various means.

You can pay:

• Online at _________, by credit or debit card.
• Through the mail, by check.
• or by calling us at (888) 227-7940

You can leave the Medicare Prescription Payment Plan at any time by
Calling: (888) 227-7940
Writing: 9450 SW Gemini Dr. #87234 Beaverton, OR 97008
and opt out by visiting our member portal (Coming Soon). Leaving won’t affect your Medicare drug coverage and other Medicare benefits.

Keep in mind:

• Your participation in the Medicare Prescription Payment Plan will end if you leave or change your Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage Plan with drug coverage). Contact your new plan if you’d like to participate in the Medicare Prescription Payment Plan again.
• If you still owe a balance, you’re required to pay the amount you owe, even though you’re no longer participating in this payment option.
• You can choose to pay your balance all at once or be billed monthly.
• You’ll pay the pharmacy directly for new out-of-pocket drug costs after you leave the Medicare Prescription Payment Plan.

While the Medicare Prescription Payment Plan helps to manage your costs, it doesn’t lower your costs. If you have limited income and resources, find out if you’re eligible for one of these programs:

• Extra Help: A Medicare program that helps pay your Medicare drug costs. Visit ssa.gov/medicare/part-d-extra-help to find out if you qualify and apply. You can also apply with your State Medical Assistance (Medicaid) office. Visit Medicare.gov/ExtraHelp to learn more.
• Medicare Savings Programs: State-run programs that might help pay some or all of your Medicare premiums, deductibles, copayments, and coinsurance. Visit Medicare.gov/medicare-savings-programs to learn more.
• State Pharmaceutical Assistance Programs (SPAPs): Programs that may include coverage for your Medicare drug plan premiums and/or cost sharing. SPAP contributions may count toward your Medicare drug coverage out-of-pocket limit. Visit go.medicare.gov/spap to learn more.
• Manufacturer’s Pharmaceutical Assistance Programs (sometimes called Patient Assistance Programs (PAPs)): Programs from drug manufacturers to help lower drugs costs for people with Medicare. Visit go.medicare.gov/pap to learn more. Many people qualify for savings and don’t realize it. Visit Medicare.gov/basics/costs/help, or contact your local Social Security office to learn more. Find your local Social Security office at ssa.gov/locator

We have detailed information on our M3P webpage. Medicare has also provided a website, a summary sheet, and a detailed Fact Sheet with additional information about the Medicare Prescription Payment Plan.

To learn more about the Medicare Prescription Payment Plan (M3P), to opt in to participate or to opt out to remove yourself from the payment plan, or if you would like general information about payments, future payments or other general information, please call Capital Rx Customer Service at (888) 227-7940 24 hours a day/7 days a week/365 days a year.

Below are some important links for your convenience and to help you find information about your pharmacy benefits and services quickly.

Drug List or Formulary

Directory or Pharmacy Network

Pharmacy Member Portal (Coming Soon)

Coverage Determination and Appeals

File a Grievance