Frequently Asked Questions
WHAT IS MEDALISTRX?
MedalistRx is a full-service national pharmacy benefits manager (PBM) that provides members like you with innovative solutions that help lower the total cost of prescriptions while improving member health.
WHAT IS A PBM?
A pharmacy benefit manager (PBM) is a company that 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.
I’M NEW TO MEDALISTRX; DO I NEED TO CHANGE FROM MY CURRENT PHARMACY?
In almost every case, you will be able to continue to use your current pharmacy. We have over 64,000 pharmacies that we have partnered with in the United States including your local independent or regional pharmacy. Simply provide your new Health ID card information to the pharmacy when you fill a prescription. This will ensure you only pay the member out-of-pocket expense for your prescription.
If your pharmacy does not accept MedalistRx, call our Member Services Helpline at our toll-free number
1-855-MEDALRX (1-855-633-2579) so we can contact your pharmacy and enroll them in our network.
WHERE CAN I FIND THE CLOSEST MEDALISTRX IN-NETWORK PHARMACY NEAR MY HOME?
MedalistRx has over 64,000 in-network pharmacies all over the United States. What this means is that there is a very good likelihood that the pharmacy you currently go to is in the MedalistRx network. However, you can always make sure that they are in the network by viewing a complete list of pharmacies that are closest to you by visiting the Pharmacy Locator.
WHAT IS A FORMULARY? WHAT IS A COPAY?
A Formulary is a listing of the Preferred Drug List (PDL) that is covered in conjunction with MedalistRx and your health plan. The Formulary shows you the Tier levels that a specific drug falls into, if there are any prior authorization requirements associated with the drug, and if there are any quantity limits on the drug.
A Copay is the amount that you would pay at the pharmacist for the drug prescription that you receive. There
are different copay levels that are determined by your health plan and these can be found in the Schedule of Benefits package. The copay that you pay is determined by the Tier level that the particular prescription drug falls into.
You can view the MedalistRx Formulary online by clicking here.
I HAVE AN ELIGIBILITY QUESTION. I HAVE A CLAIMS QUESTION. OR I HAVE OTHER QUESTIONS. WHO DO I CONTACT?
MedalistRx is here to answer all your questions. So fire away and ask them all!
Call our toll-free Member Services Helpline at 1-855-MEDALRX (1-855-633-2579) and our Member Services representatives will answer any question related to your pharmacy benefit program.
WHEN CAN I CALL THE MEDALISTRX MEMBER SERVICES HELPLINE?
You can call us anytime! Call us right now. Call us tomorrow. Call us at midnight. Call us a week from now. We would say you could have called us yesterday but they haven’t finished inventing the time machine yet (we are working with the geniuses on that).
Call our toll-free Member Services Helpline at 1-855-MEDALRX (1-855-633-2579) and ask us all the questions
Membership Questions
I LOST OR SOMEONE STOLE MY CARD. HOW DO I ORDER ANOTHER ID CARD?
A temporary ID card is available online for your use until we can mail a new one out to you.
Simply log in into the Member Login section and order a new ID card. For additional or replacement ID cards, you can also contact our toll-free Member Services Helpline at 1-855-MEDALRX (1-855-633-2579).
WHY IS THE PHARMACIST SUGGESTING A GENERIC OR ALTERNATIVE BRAND MEDICATION FOR ME?
At times, your pharmacist may suggest a generic or an alternative brand prescription instead of the prescription originally prescribed to you. These alternative prescriptions provide the same health outcomes as the original prescription prescribed by the physician. In addition, the new alternative also provide the most cost effective
co-pay for you to pay out of your own pocket.
If you have any concerns or questions about the medications that are prescribed to you, please consult with your local pharmacist or call our toll-free Member Services Helpline at 1-855-MEDALRX (1-855-633-2579).
HOW DO I KNOW IF THE HEALTH PLAN COVERS A PRESCRIPTION? HOW DO I KNOW WHAT MY COPAY WILL BE FOR THE PRESCRIPTION?
MedalistRx has a preferred drug list, which is also known as a formulary. This formulary lets you know if the drug you are taking is covered by the health plan. When you type in the drug name, you will also receive information that states what Tier the drug falls into, if the drug is subject to any prior authorizations, if there are any quantity limits, etc.
The formulary also lets you know what your copayment will be on the drug. When the drug name is typed in, it will list what Tier level the drug is in. This tier level determines what the copayment will be on the drug. While the formulary does not specifically include the copay dollar amount that will be paid at the pharmacy, you can refer to the Schedule of Benefits in your Health Plan package to see the dollar copay amounts according to its respective Tier levels.
Please note that the online formulary document does not list every covered medication as its a very expansive list. If your drug doesn’t appear, please contact the Member Services Helpline at 1-855-MEDALRX (1-855-633-2579) to find out the coverage associated with your drug request.
I’M TRAVELING ON VACATION OR BUSINESS. HOW DO I FILL MY PRESCRIPTION?
First of all, congratulations on getting to go on vacation. We at MedalistRx applaud you! If you’re traveling on business, we hope that it is fun and entertaining for you too!
Aaah yes…the age old question of how to fill a prescription in advance.
It’s this simple: Call our toll-free Member Services Helpline at 1-855-MEDALRX (1-855-633-2579) and tell our world-class Member Service representatives of your situation and your need to fill a prescription in advance.
Account Questions
THE PHARMACIST IS TELLING ME MY PRESCRIPTIONS ARE NOT COVERED?
Please be sure to present your new ID card to your pharmacist and ask them to check if they are processing your new information. The best way to ensure appropriate coverage is to have your ID card available each time you visit the pharmacy. If presenting your new card does not resolve the issue, please call our toll-free Member Services Helpline at
1-855-MEDALRX (1-855-633-2579) and speak with a Member Services representative who will take care of your needs.
WHAT DO I NEED TO DO TO BEGIN USING MAIL-ORDER SERVICE?
Each person using the mail order service will need to enroll in OptumRx’s Mail-Order Service.
This can be done by simply enrolling online at www.optumrx.com and follow the simple prompts to place your order. You can also complete the Mail Order Service Form and MAIL the order form to OptumRx, P.O. Box 509075, San Diego, CA 92150-9075 or FAX the order form to (800) 491-7997 .
The third option would be to call OptumRx Member Services toll free at 1 (800) 797-9791.
New prescriptions written for a 90-Day Supply should be sent to OptumRx by your Physician’s office.
HOW DOES THE MAIL ORDER PHARMACY RECEIVE PRESCRIPTION ORDERS?
As a MedalistRx member that is registered for Mail-Order service from OptumRx, prescriptions can be taken only via phone or a completed fax form from your physician. As a member, you cannot turn in this information to OptumRx in order to fill prescriptions.
First time patients can mail the original prescriptions with a completed Mail Order Service Form to OptumRx for fulfillment. For refills, all a member needs to do is have the physician certify that the prescriptions can be refilled and the time period for the fills.
WHO AND WHAT IS OPTUMRX MAIL ORDER?
MedalistRx is your Prescription Benefit Manager for all your prescription needs. MedalistRx has a strategic partnership with OptumRx Pharmacy for the fulfillment of Mail-Order pharmacy prescriptions that are serviced through MedalistRx. This partnership was built to ensure the highest quality of service for both your retail and mail order needs.
OptumRx is based in the same cities as MedalistRx and can fulfill the mail-order needs of MedalistRx members all over the United States through their world-class mail-order facilities.