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PRESCRIPTION DRUG COVERAGE

Your prescription drug coverage includes generic, preferred brand, nonpreferred brand and specialty drugs. You must enroll in a Children’s Mercy medical plan to receive prescription drug coverage.

We use step therapy for certain medications. Step therapy is a process that helps ensure you receive generic or lower-cost brand-name options that are as effective as medications that cost more. You may be approved to begin using step therapy medications automatically, based on your claims history and information from your provider. No action is needed on your part; you’ll be notified if step therapy impacts your future prescriptions.

HOW THE BLUE PLAN, GOLD PLAN AND GREEN PLAN COVER PRESCRIPTIONS

GOLD PLAN BLUE PLAN GREEN PLAN
Retail (30-day supply)
  • Generic
  • Preferred Brand*
  • Nonpreferred Brand

 

 
  • $8
  • 30% up to $75
  • 50% up to $150
Prescriptions on the Affordable Care Act (ACA) preventive prescription drug list***: Covered at 100%
  • $8
  • 30% up to $75
  • 50% up to $150

Prescriptions on the ACA preventive prescription drug list***: Covered at 100%

You pay the full, negotiated cost before you meet your deductible; after you meet your deductible you pay 20% coinsurance and CM pays 80%

Prescriptions on the ACA preventive prescription drug list***: Covered at 100%

Prescriptions on the Green Plan preventive drug list****: Deductible waived; 20% coinsurance

Maintenance (31-90 day supply) and Mail Order (90-day supply)
  • Generic
  • Preferred Brand*
  • Nonpreferred Brand

 

 
  • $18
  • 30% up to $150
  • 50% up to $375

Prescriptions on the ACA preventive prescription drug list***: Covered at 100%
  • $18
  • 30% up to $150
  • 50% up to $375

Prescriptions on the ACA preventive prescription drug list***: Covered at 100%

You pay the full, negotiated cost before you meet your deductible; after you meet your deductible you pay 20% coinsurance and CM pays 80%

Prescriptions on the ACA preventive prescription drug list***: Covered at 100%

Prescriptions on the Green Plan preventive drug list****: Deductible waived; 20% coinsurance
Specialty
  • Generic
  • Preferred Brand*
  • Nonpreferred Brand
  • 30% up to $200
  • 30% up to $200
  • 50% up to $200
  • 30% up to $200
  • 30% up to $200
  • 50% up to $200

You pay the full, negotiated cost before you meet your deductible; after you meet your deductible you pay 20% coinsurance and CM pays 80%

Prescription Drug Out-of-Pocket Maximum

$1,600 per person/$5,800 family**

$1,600 per person/$5,800 family**

Prescription drug costs are combined with your medical costs to meet your medical out-of-pocket maximum (there is no separate out-of-pocket maximum for prescription drugs)**

*Minimum per-prescription costs do not apply to prescriptions subject to Dispense as Written (DAW) provisions. In addition, ancillary costs due to DAW do not count toward your annual out-of-pocket maximum. Disposable insulin delivery systems and supplies (Omnipod 5, Omnipod Dash, V-Go) are covered through the Rx benefit with an approved prior authorization. These products are subject to quantity limits and will have a brand preferred member cost share.

** Summary of infertility prescription benefits:

  • $5,000 lifetime maximum allowable benefit 50% of cost/coinsurance.
  • Infertility coinsurance does not apply to out-of-pocket maximum.
  • After reaching the $5,000 lifetime maximum, you'll pay 100%.
  • Green Plan members will pay 100% of infertility prescriptions until the deductible is met. Then members will pay 50% for infertility prescriptions until reaching the $5,000 lifetime max.

*** Click for more information about ACA preventive care covered prescriptions.

**** Click for the Green Plan preventive drug list.

Learn more about your prescription drug coverage.
  • Depending on the plan, you pay nothing or less out of pocket for preventive prescriptions.

    In the Gold Plan, Blue Plan and Green Plan, preventive prescriptions on the ACA preventive prescription drug list are covered at 100%. Preventive drugs are used to help avoid disease and maintain health, and examples include medications for asthma, bone disease and diabetes. Generic contraceptives and brand-name contraceptives without a generic equivalent also are preventive prescriptions. See the ACA preventive prescription drug list.

    In the Green Plan, the deductible is waived for certain additional preventive prescriptions, and you pay only the 20% coinsurance. Refer to the Green Plan preventive prescription drug list.

  • You pay less for preferred brand-name drugs and usually even less for generic drugs.

    The preferred drug list includes medically effective drugs that help control costs. Preferred brand-name drugs are available at a lower coinsurance rate than nonpreferred brand drugs.

  • Prescription drugs must be dispensed as they’re prescribed by the physician.

    For example, if your provider prescribes you a generic drug, you may not request the brand-name equivalent from the pharmacy. No substitutions or changes will be accepted. Be sure to discuss your prescription with your physician if you prefer a brand-name drug.

  • There are some specific rules to know, based on your medical plan.

    In the Gold Plan and Blue Plan, there are separate out-of-pocket maximums of $1,600 per person for prescription drug coverage. (Prescription drug costs for infertility treatment do not count toward the out-of-pocket maximum.) Prescription drug expenses do not count toward the medical plan deductible or out-of-pocket maximum, and other covered medical expenses do not count toward the prescription drug out-of-pocket maximum. In addition, you cannot use your Children’s Mercy-funded Health Reimbursement Account to pay for prescriptions. In the Green Plan, prescription drug costs are combined with your medical costs to meet your medical out-of-pocket maximum (there is not a separate out-of-pocket maximum for prescription drugs).

  • Get specialty prescriptions from US Specialty.

    US Specialty, WellDyne’s wholly owned specialty pharmacy, is an industry-leading provider of specialty medications. Committed to providing personalized care and to ensuring you have the tools to understand and manage your condition, US Specialty Care representatives are available at (800) 641-8475, and more information is online at www.usspecialtycare.com. And, see the specialty prescription drug list.

HOW TO FILL YOUR PRESCRIPTIONS

There are several ways to fill your prescriptions:

Employee Wellness Center Retail Maintenance Program Mail Order
Use it to Fill any prescription at the Employee Wellness Center pharmacy, even if you are not covered by a Children’s Mercy medical plan. For your convenience, the pharmacy offers a prescription drug delivery service at the Adele Hall Campus and Children’s Mercy Broadway. Learn more. Fill any prescription the first or second time at an in-network pharmacy Fill maintenance medications (used on an ongoing basis) at your local Walgreens pharmacy Fill maintenance medications (used on an ongoing basis) through the mail-order program
Receive Up to a 90-day supply Up to a 30-day supply A 90-day supply Up to a 90-day supply