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Web prescription reimbursement claim form important! In tx, services provided by ingenio, inc. The carelonrx name and carelonrx logo are registered trademarks. Web page 1 of 3 patient name: Creating an account is free, easy and helps. Web pa requests are received electronically or through our interactive care reviewer (icr) portal. Step 1 card holder/patient information. Web prescription reimbursement claim form important! Use your card on file. Web this can be located on your medical id card (if you have a combined medical and pharmacy card), on your pharmacy card, or by calling the member services prior. Web complete drug list four tier drug plan your prescription benefit comes with a drug list, which is also called a formulary.