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Prescription Drug Plan Copayment Summary

Copay Summary

Plan Copayment Year Retail PPL* (In-Network)/non-PPL (Out of Network) Copay

(Per 30-day supply)

Mail Copay

(Per 90-day supply)

Non-Preferred Drug Surcharge (Per 30-day Supply)
UMWA Combined Benefit Fund March 27 – March 26 $5/$5** $0 No
UMWA 1992 Benefit Plan Jan 1 – Dec 31 $5/$5** $0 No
1993 Plan Traditional Program of Benefits Jan 1 – Dec 31 $15/$30 $5 No
1993 Plan Alternate Program of Benefits Jan 1 – Dec 31 $25/$40 $10 No
1993 Plan Post-Legislative Program of Benefits Jan 1 – Dec 31 $15/$30 $5 No
1993 Plan Individual Employer Program of Benefits (Eligible Active Employees and Non-Coal Act Retirees of Murray American Energy, Inc. and its related entities) Jan 1 – Dec 31 $20/$35 $30 1st fill – $0

1st refill – $10 (plus copay)

Additional refills – $20 (plus copay)

1993 Plan Section 9711 Program and Benefits (Eligible Coal Act Retirees of Murray American Energy, Inc. and its related entities) Jan 1 – Dec 31 $5/$5** $0 1st fill – 0

1st refill – $10 (plus copay)

Additional refills – $20 (plus copay)

 

1993 Plan UMWA Program of Benefits (Eligible Employees and Retirees of UMWA) Jan 1 – Dec 31 $20/$35 **** $30 1st fill – $0

1st refill – $10 (plus copay)

Additional refills – $20 (plus copay)

1993 Plan Individual Employer Program of Benefits (Murray Oak Grove Coal, LLC) Jan 1 – Dec 31 $5/$10** $0 1st fill – $0

1st refill – $7.50 (plus copay)

Additional refills – $15 (plus copay)

UMWA Prefunded Benefit Plan—Carbontronics Jan 1 – Dec 31 $15/$30 $5 No
UMWA Prefunded Benefit Plan–Eligible Coal Act Retirees of Energy West Mining Company Jan 1 – Dec 31 $5/$5** $0 No
UMWA Prefunded Benefit Plan–Eligible Non-Coal Act Retirees of Energy West Mining Company Jan 1 – Dec 31 $15/$30*** $5 No

*PPL-Participating Provider Lists​

**Maintenance Choice Program – If a 90-day supply is obtained at a CVS retail pharmacy – $0 copay per 90-day supply

***Maintenance Choice Program – If a 90-day supply is obtained at a CVS retail pharmacy – $5 copay per 90-day supply

****Maintenance Choice Program – If a 90-day supply is obtained at a CVS retail pharmacy – $30 copay per 90-day supply

 

 

Other information about above plans:

Specialty Pharmacy Medications are limited to a 30-day supply.

Beneficiaries will need to submit a manual claim; higher copayments may apply.

Non-preferred specialty medications require medical necessity approval and evidence of failure with preferred drugs before coverage is allowed.​