|
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.