Medical Copayment Summary
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UMWA Health and Retirement Funds

Medical Copayment Summary

 

Co-payment Information
 
Combined Benefit Fund
1992 Benefit Plan 
Co-payment Year
March 27 – March 26
January 1 – December 31
Co-payment Per
Physician Visit (Inpatient, Physician office Emergency Room, Routine & Well Baby care)
$5
$5
Annual Physician Co-Payment Family Maximum
$100
$100
Hospital Co-Payment
 
N/A
N/A
Co-Payment Per
Prescription
$5
$5
Mail Order Prescription
Co-Payment
$0 per 90 day fill
$0 per 90 day fill (first fill per prescription must be for 30 days)
Annual Prescription Co-Payment Family Maximum
$50
$50
Annual Family Out of Pocket Maximum
N/A
N/A

 

Co-payment Information
 
1993 Benefit Plan 
Prefunded Benefit Plan
Alternate Program of Benefits
Co-payment Year
January 1 – December 31
January 1 – December 31
Co-payment Per
Physician Visit (Inpatient, Physician office, Emergency Room, Routine and Well Baby care)
$20 (PPL Network)
$30 (Non-Network)
$30 (PPL Network)
$40 (Non-Network)
Outpatient X-Rays, Tests, Allergy Shots, Therapeutic Injections, Therapy visits (ST, PT, OT), and Mental Health/Substance Abuse visits
N/A
$30 (PPL Network)
$40 (Non-Network)
Annual Outpatient/Physician Co-Payment Family Maximum
$400 (PPL Network)
$400 (Non-Network)
$500 (PPL Network)
$500 (Non-Network)
Annual Inpatient Hospital Co-Payment Family Maximum
N/A (PPL Network)
$600 (Non-Network)
$750 (PPL Network)
$750 (Non-Network)
Co-Payment Per
Prescription
$15 (PPL Network)
$30 (Non-Network)
$25 (PPL Network)
$40 (Non-Network)
Mail Order Prescription
Co-Payment
$5 per 90 day fill
$10 per 90 day fill
 
Annual Prescription Co-Payment Family Maximum
$600 (PPL Network)
$600 (Non-Network)
$1000 (PPL Network)
$1000 (Non-Network)
Annual Family Out of Pocket Maximum
$1600 (medical and prescription combined)
$2250 (medical and prescription combined)