1992 Benefit Plan
Copayment Year |
January 1 – December 31 |
Copayment Per
Prescription |
$5 |
Mail Order Prescription
Copayment |
$0 per 90 day fill |
Annual Prescription Copayment Family Maximum |
$50 |
Alternate Program of Benefits
Copayment Year |
January 1 – December 31 |
Copayment Per
Prescription |
$25 (PPL Network)
$40 (Non-Network) |
Mail Order Prescription
Copayment |
$10 per 90 day fill |
Annual Prescription Copayment Family Maximum |
$1000 (PPL Network)
$1000 (Non-Network) |
Family Out-of-Pocket Maximum |
$2250 (includes Medical) |
1993 Benefit Plan
Copayment Year |
January 1 – December 31 |
Copayment Per
Prescription |
$15 (PPL Network)
$30 (Non-Network) |
Mail Order Prescription
Copayment |
$5 per 90 day fill |
Annual Prescription Copayment Family Maximum |
$600 (PPL Network)
$600 (Non-Network) |
Family Out-of-Pocket Maximum |
$1600 (includes Medical) |
Combined Benefit Fund
Copayment Year |
March 27 – March 26 |
Copayment Per
Prescription |
$5 |
Mail Order Prescription
Copayment |
$0 per 90 day fill |
Annual Prescription Copayment Family Maximum |
$50 |
Prefunded Benefit Plan
Copayment Year |
January 1 – December 31 |
Copayment Per
Prescription |
$15 (PPL Network)
$30 (Non-Network) |
Mail Order Prescription
Copayment |
$5 per 90 day fill |
Annual Prescription Copayment Family Maximum |
$600 (PPL Network)
$600 (Non-Network) |
Family Out-of-Pocket Maximum |
$1600 (includes Medical) |
UMWA 1993 Individual Employer Program Benefits ("Actives and Retirees")
Copayment Year |
January 1 – December 31 |
Copayment Per
Prescription |
$20 per 30-day supply |
Mail Order Prescription
Copayment |
$10 per 30-day supply |
Annual Prescription Copayment Family Maximum |
$1,000 |
Coverage for Preventive Therapy (ACA) |
YES |
| Surcharges apply for non-preferred drugs |
1st fill - $0;
2nd fill - $10;
3rd fill plus - $20 (all per 30 days) |
UMWA 1993 Section 9711 Program and Benefits
Copayment Year |
March 27 - March 26 |
Copayment Per
Prescription |
$5 per 30-day supply |
Mail Order Prescription
Copayment |
$0 for up to 90 days |
Annual Prescription Copayment Family Maximum |
$50 |
Coverage for Preventive Therapy (ACA) |
YES |
| Surcharges apply for non-preferred drugs |
1st fill - $0;
2nd fill - $10;
3rd fill plus - $20 (all per 30 days) |
Other information about above plans:
Specialty Pharmacy Medications limited to a 30-day supply
Claims will not process through a non-participating or non-preferred pharmacy. Will need to submit manual claims
Non-preferred specialty medications require