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.

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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
$1,600 per person**†

*  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
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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.