Pharmacy

Capstone Health Plan contracts with Partners Rx for pharmacy benefit management (PBM) services. Please review the links and documents provided under Resources on your right for additional information pertaining to pharmacy benefits for Capstone Members.

Partners Rx offers a comprehensive network of pharmacies nationwide. The pharmacy locator can be accessed through the Partners Rx web site.

Please be sure to refer to the Capstone Formulary prior to writing a Member's prescription. Whenever possible, prescriptions should be written for the generic equivalent per the formulary.

Medication Prior Authorization

Certain brand name medications, step therapies and all non-formulary medications require a prior authorization to be obtained by filling out the Medication Prior Authorization Request Form. The Medication PA form must document the medical necessity for the medication, and why generic or formulary medications cannot be used.

Complete the entire request form and fax to Partners Rx at: (800)-527-0531.

You may also contact Partners Rx to expedite your request at: (800) 711-4555.

Please obtain prior authorization approval before the patient goes to the pharmacy.

Mail Order Pharmacy

Partners Rx offers a prescription mail order service through Prescription Solutions. All maintenance medications must be filled through the mail order service. Please refer to the Mail Order Form for assistance in writing prescriptions for maintenance medications.

Pharmacy Limitations

Capstone Health Plan cannot, under Federal guidelines, pay for Medicare prescription co-pays or deductibles. Capstone does not pay for medications that are covered by Children's Rehabilitative Services (CRS) or Regional Behavioral Health Authorities (RBHAs). Prescriptions written by CRS or RBHA providers for a member enrolled in CRS or RBHA are covered by CRS or RBHA, not Capstone. PCPs should not write prescriptions for the memberŐs CRS or RBHA conditions; instead please refer your patient back to their appropriate specialist(s).

Members with chronic behavioral health conditions, who need antipsychotic or multiple behavioral health drugs, should be referred to RBHAs for psychiatric care. Capstone has a sixty (60) day limitation on coverage of psychotropic medications to ensure therapy continuation while the member is transferred to a RBHA. Please see the Behavioral Health section of the Provider Manual for additional information regarding Capstone coverage of these medications or call the Health Services department.

Capstone Health Plan