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.
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 |
| Non-Preferred 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 the Blue Plan with family coverage, your out-of-pocket maximum for prescription drug coverage will not exceed $5,800.
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 non-preferred 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.