Prescription Drug Coverage
- Specialty Prescription Drugs
- Prior Authorization for certain prescriptions
- Quantity Limit
- Preferred Drug Step Therapy
- Exclusion of Compound Medications
- RationalMed Drug Safety Program
| MetroHealth Select | Medical Mutual Value Plan | Medical Mutual Traditional Plan | ||||
|---|---|---|---|---|---|---|
| Prescription Drug Benefits | MetroHealth Pharmacy | Medical Mutual Express Scripts | Medical Mutual Express Scripts | Non-Network | Medical Mutual Express Scripts | Non-Network |
| Retail Drug (30 day supply) Mandatory Generic Non-Maintenance, Non-Specialty Drugs | ||||||
| Retail Generic (30 day supply) | $0 copay | $10 copay | $15 copay | Not covered | $10 copay | Not covered |
| Retail Preferred Brand Name (30 day supply) | $30 copay | $45 copay | $50 copay | Not covered | $40 copay | Not covered |
| Retail Non-Preferred Brand (30 day supply) | $60 copay | $90 copay | $95 copay | Not covered | $75 copay | Not covered |
| Mail Order Non-Specialty (90 Day Supply) Mandatory Generic Maintenance Drugs | ||||||
| Mail Generic | $10 copay | $20 copay | $30 copay | Not covered | $20 copay | Not covered |
| Mail Preferred Brand | $60 copay | $90 copay | $100 copay | Not covered | $80 copay | Not covered |
| Mail Non-Preferred Brand | $120 copay | $180 copay | $190 copay | Not covered | $150 copay | Not covered |
| Specialty Drugs (Accredo Specialty Pharmacy only) | ||||||
| 30 Day Supply | Not covered | Retail copays apply | 10% up to $200 max per prescription | Not covered | 10% up to $175 max per prescription | Not covered |
| Out-of-Pocket Maximum: Includes Deductible, Copay, and Coinsurance for Medical and Prescription Drugs | ||||||
| Individual | $8,150 | Unlimited | $8,150 | Unlimited | $8,150 | Unlimited |
| Family | $16,300 | $16,300 | $16,300 | |||
MetroHealth Select Prescription Drug Coverage
MetroHealth Select participants also have access to Medical Mutual Retail and Home Delivery Pharmacy Network through Express Scripts. Members can have prescriptions filled up to a 30-day supply at a network retail pharmacy and/or use the Express Scripts Home Delivery Pharmacy services to fill prescriptions for a 90- day supply of maintenance medications at an increased copayment cost.
The medical plans through CSU include a Prescription Drug Cost Management Program. Specialty prescription drugs are included within the Prescription Drug Cost Management Program. MetroHealth participants have access to the two providers from Medical Mutual for specialty medications—Accredo Specialty Pharmacy or Gentry Health Services. It is important to note that prescriptions for specialty medications must be filled through the Accredo Specialty Pharmacy, or Gentry Health Services. Accredo Specialty Pharmacy and Gentry Health Services are the sole sources for direct delivery of specialty medications. The cost of prescriptions for specialty medications filled at any other pharmacy will be the responsibility of the participant.
Medical Mutual Value and Traditional Prescription Drug Coverage
Medical Mutual provides access to its Retail and Home Delivery Pharmacy Network through Express Scripts®. Members can get prescriptions filled up to a 30-day supply at a network retail pharmacy and/or use the Express Scripts® Home Delivery Pharmacy services to fill prescriptions for a 90-day supply of maintenance medications for the retail cost of two-months copayments. Contact Express Scripts® at 800.282.2881 or online at express-scripts.com to locate a network retail pharmacy or for details as to how to use mail order pharmacy services.
Specialty prescription drugs are included within the Prescription Drug Cost Management Program. It is important to note that prescriptions for specialty medications must be filled through the Medical Mutual Specialty Drug Solution—Accredo Specialty Pharmacy or Gentry Health Services. Accredo Specialty Pharmacy and Gentry Health Services are the sole sources for direct delivery of specialty medications. The cost of prescriptions for specialty medications filled at any other pharmacy will be the responsibility of the participant. Refer to Prescription Drug Coverage section of this booklet for more information.
