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Rx Copay Summary

Rx Copay Summary

The amount you will need to pay for prescription drugs depends on the Funds’ 计划 in which you are enrolled. The copayment year, the copayment amount and the maximum out-of-pocket amount is different for each 计划 listed below. If you have any questions, please call the Call Center at 1-800-291-1425, option 2.

计划 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 计划 Jan 1 – Dec 31 $5/$5** $0 No
1993 计划 Traditional Program of Benefits Jan 1 – Dec 31 $15/$30 $5 No
1993 计划 Alternate Program of Benefits Jan 1 – Dec 31 $25/$40 $10 No
1993 计划 Post-Legislative Program of Benefits Jan 1 – Dec 31 $15/$30 $5 No
1993 计划 Individual Employer Program of Benefits (Eligible Active Employees of American Consolidated Natural Resources, 公司. 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 计划 Individual Employer Program of Benefits (Crimson Oak Resources, 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 计划—Carbontronics Jan 1 – Dec 31 $15/$30 $5 No
UMWA Prefunded Benefit 计划–Eligible Coal Act Retirees of Energy West Mining Company Jan 1 – Dec 31 $5/$5** $0 No
UMWA Prefunded Benefit 计划–Eligible Non-Coal Act Retirees of Energy West Mining Company Jan 1 – Dec 31 $15/$30*** $5 No

*PPL-Participating Provider Lists​

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

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

****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.​