Your prescription drug coverage, administered by WellDyne, 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.
GOLD PLAN | BLUE PLAN | GREEN PLAN | |
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Retail (30-day supply) | |||
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You pay:
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You pay:
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) | |||
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You pay:
Prescriptions on the ACA preventive prescription drug list***: Covered at 100% |
You pay:
Prescriptions on the ACA preventive prescription drug list***: |
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 | |||
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You pay:
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You pay:
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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 |
You pay: $1,600 per person/$5,800 family** |
You pay: $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:
*** Click for more information about ACA preventive care covered prescriptions.
**** Click for the Green Plan preventive drug list.
There are several ways to fill your prescriptions:
Take CARE Employee Clinic and Pharmacy | Retail | Maintenance Program | Mail Order | |
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Use it to | Fill any prescription at the Take CARE Employee Clinic and 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 |