Our New Pharmacy Benefit Program: What It Means for You

Immediate Help & Key Changes

Change can sometimes create confusion, especially when it involves your health care. If you've felt puzzled by a cost or questioned a prescription's coverage since our transition, please know that your questions are normal. We are here to help you navigate our new pharmacy program with Capital Rx.

The most important step you can take for immediate help is to call our dedicated support line. If you have an issue or a question about your coverage, please call this number right away and keep it handy:

Capital Rx Customer Service

(866) 957-7862

This dedicated team is ready to research your specific claim, explain coverage changes, and resolve issues immediately.

Why We Switched and What’s New

By now, you’ve probably heard that Cook Children’s has moved to a new Pharmacy Benefit Manager (PBM) called Capital Rx. A PBM is simply the company that manages our prescription drug plan.

The move to Capital Rx (from CVS Caremark) is a strategic step to create a stable, long-term, and innovative prescription drug program for you and your family. We chose Capital Rx for a model centered on:

• Transparency: Greater visibility allows us to make smarter, more cost-effective decisions –ultimately helping keep our benefits affordable.
• Flexibility: We can make sure the drug list is designed with your needs in mind –focusing on safe, effective, and affordable options –rather than relying on a one-size fits all approach from a third party. We can prioritize drugs that are clinically effective and the most cost-efficient.
• Local Support: We now have access to a large network of pharmacies, including big chains, and local stores, and we worked to ensure Cook Children’s retail pharmacies are part of the network.
• Best Value: The new model focuses on cost-effective and clinically sound drugs.

You May See Changes: What to Know

Our new program with Capital Rx went live on Oct. 1, 2025. While most members are not seeing issues, a few things may be causing some people to see higher costs right now:

• Deductible Reset: If you are on an HSA medical plan, your annual deductible reset on October 1st. This is normal at the start of a new plan year. This means you will pay the full contracted price for medications until you meet that new deductible. This is unrelated to the PBM change.
• Zero Co-pay List Adjustment: We updated the zero co-pay list. Most generic drugs will remain $0 co-pay, but a co-pay was assessed for most brand-name drugs.
• New Clinical Programs: We’ve implemented a split-fill program for high-cost specialty medications (e.g., certain cancer treatments) to ensure the drug is right for you before filling a full month.

We Are Here to Help

We take every reported issue seriously. If you experience an issue with your prescription coverage or cost, please know that Capital Rx, Cook Children’s, and our consulting partners are working together to find a resolution. If a drug is not covered, both Capital Rx and Cook Children’s have an exceptions process. You also have the right to an internal appeals process with Cook Children’s.

We know that managing prescription benefits is essential for you and your family's well-being. Thank you for your patience as we navigate this transition toward a more transparent and sustainable program. We appreciate you taking the time to understand these changes, and we encourage you to use the dedicated support line whenever you need assistance. Our commitment is to ensure this new system delivers the best care and value possible.