Prescription Drug Coverage
Prescription drug coverage is included as part of the medical plan you choose. Your medical ID card also serves as your prescription drug card. MetroHealth Select (Skyway) provides prescription drug coverage through both MetroHealth Pharmacy and Express Scripts, while Medical Mutual offers prescription drug coverage exclusively through Express Scripts.
- Specialty Drug Solution Program
- Prior Authorization for certain prescriptions
- Quantity Limits
- Preferred Drug Step Therapy
- RationalMed Drug Safety Program
Compounded medications are not covered; members pay the full cost.
More details on Prescription Drug Cost Management Programs are located on Medical Mutual’s website at medmutual.com.
| MetroHealth Select (Skyway) | Medical Mutual Value Plan | Medical Mutual Traditional Plan | ||||
|---|---|---|---|---|---|---|
| Prescription Drug Benefits | In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network |
| Retail Drug (up to a 30-day supply) Mandatory Generic Non-Maintenance, Non-Specialty Drugs | ||||||
| Retail Generic (30-day supply) | $0 copay | $10 copay | $15 copay | Not covered | $15 copay | Not covered |
| Retail Preferred Brand Name (30-day supply) | $30 copay | $45 copay | $50 copay | Not covered | $50 copay | Not covered |
| Retail Non-Preferred Brand (30-day supply) | $60 copay | $90 copay | $95 copay | Not covered | $95 copay | Not covered |
| Mail Order Non-Specialty (90-day Supply) Mandatory Generic Maintenance Drugs | ||||||
| Mail Generic | $10 copay | $20 copay | $30 copay | Not covered | $30 copay | Not covered |
| Mail Preferred Brand | $60 copay | $90 copay | $100 copay | Not covered | $100 copay | Not covered |
| Mail Non-Preferred Brand | $120 copay | $180 copay | $190 copay | Not covered | $190 copay | Not covered |
| Specialty Drugs (Accredo Specialty Pharmacy only) | ||||||
| 30-Day Supply | 10% up to $100 | 10% up to $100 | 10% up to $200 max per prescription | Not covered | 10% up to $200 max per prescription | Not covered |
| Deductible (calendar year January 1–December 31) | ||||||
| Employee | $350 | Not covered | $1,100 | $2,200 | $600 | $1,200 |
| Family | $1,050 | Not covered | $3,300 | $6,600 | $1,800 | $3,600 |
| Coinsurance | 20% | Not covered | 20% | 40% | 25% | 40% |
| Out-of-Pocket Maximum: Includes Deductible, Copay, and Coinsurance for Medical and Prescription Drugs | ||||||
| Employee | $3,500 | Unlimited | $5,000 | Unlimited | $4,000 | Unlimited |
| Family | $7,000 | Unlimited | $10,000 | Unlimited | $8,000 | Unlimited |
MetroHealth Select Prescription Drug Coverage
The MetroHealth plan provides prescription drug benefits for up to a 30-day supply of medication and a 90-day supply (retail or home delivery) of maintenance medication to control chronic health conditions. Copayments are the lowest when members use a MetroHealth pharmacy. Call 216.957.MEDS (6337) for all pharmacy needs, or go online to metrohealth.org/pharmacy
for more information.
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. Visit Prescription Drug Cost Management Programs for more information.
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. Visit Prescription Drug Cost Management Programs for more information.
