| 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 of American Consolidated Natural Resources 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 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 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.
