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Rx Copay Summary

Rx Copay Summary

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

Plan
UMWA Combined Benefit Fund
UMWA 1992 Benefit Plan
1993 Plan Traditional Program of Benefits
1993 Plan Alternate Program of Benefits
1993 Plan Post-Legislative Program of Benefits
1993 Plan Individual Employer Program of Benefits (Eligible Active Employees of American Consolidated Natural Resources, Inc. and its related entities)
1993 Plan Individual Employer Program of Benefits (Crimson Oak Resources, LLC)
UMWA Prefunded Benefit Plan—Carbontronics
UMWA Prefunded Benefit Plan–Eligible Coal Act Retirees of Energy West Mining Company
UMWA Prefunded Benefit Plan–Eligible Non-Coal Act Retirees of Energy West Mining Company
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)
March 27 – March 26 $5/$5** $0 No
Jan 1 – Dec 31 $5/$5** $0 No
Jan 1 – Dec 31 $15/$30 $5 No
Jan 1 – Dec 31 $25/$40 $10 No
Jan 1 – Dec 31 $15/$30 $5 No
Jan 1 – Dec 31 $20/$35 $30 1st fill – $0

1st refill – $10 (plus copay)

Additional refills – $20 (plus copay)

Jan 1 – Dec 31 $5/$10** $0 1st fill – $0

1st refill – $7.50 (plus copay)

Additional refills – $15 (plus copay)

Jan 1 – Dec 31 $15/$30 $5 No
Jan 1 – Dec 31 $5/$5** $0 No
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.​