Prescription Drug Coverage
PRESCRIPTION DRUG COVERAGE
Your prescription drug coverage includes generic, preferred brand, nonpreferred brand and specialty drugs. You pay a copay or coinsurance, depending on the type of drug you choose. You must enroll in a Children’s Mercy medical plan to receive prescription drug coverage.
Children’s Mercy uses 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.
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.
HOW THE PLAN COVERS PRESCRIPTIONS
| Retail | Maintenance or Mail Order | |
|---|---|---|
| Generic | $6 | $14 |
| Preferred Brand* | 30% of cost; no more than $60 | 30% of cost; no more than $150 |
| Nonpreferred Brand* | 50% of cost; no more than $150 | 50% of cost; no more than $375 |
| Per-Person Out-of-Pocket Maximum | ||
* 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.
** 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 will pay 100%.
† If you participate in family coverage, your out-of-pocket maximum for prescription drug coverage will not exceed $5,800.
Continuous Glucose Monitor coverage is covered under the Prescription Drug benefit.
Due to the Affordable Care Act, there is a separate out-of-pocket maximum for prescription drug coverage of $1,600 per person. (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.
You cannot use your Children’s Mercy-funded Health Account to pay for prescriptions.
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 |
A specialty pharmacy program, available through Walgreens, supports patients with complex health conditions who take injectable medications, medications with strict compliance requirements or other medications with special storage needs. Call 1 (800) 424-9002 or visit Walgreens for more information.
TIPS TO MANAGE YOUR PRESCRIPTION COSTS
- You pay less for preferred brand-name drugs and usually even less for generic drugs. The MedImpact 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.
- You pay nothing out of pocket for generic contraceptives and brand-name contraceptives without a generic equivalent, as these are considered preventive prescription drugs and are covered at 100 percent under Children’s Mercy medical plans. If your contraceptive prescription is for a brand-name drug and a generic equivalent is available, you are required to pay according to the plan’s normal schedule of benefits.
- To help pay prescription drug expenses, consider enrolling in the Health Care Flexible Spending Account.