plan approves an exception based on the criteria below, you will pay the Tier 2 cost share (30 percent of the allowed amount, $35 maximum payment per 30-day supply. If your exception request is denied, the plan’s response letter will include the reason for the denial and the steps you can take next. Preferred drug list exceptions and coverage determinations are based on medical necessity. Because requesting a noncovered drug exception requires medical information, only your prescribing provider may submit clinical information for review. The prescribing provider will need to provide WSRxS with the following information: • The prescribing provider’s contact information; • An explanation of why the plan should grant an exception; • An explanation of how the requested medication therapy is evidence-based and generally accepted medical practice; • Documentation of medical necessity for the requested prescription drug over all other preferred therapeutic alternatives; and • At least one of the following items must also be included with the exception request: ▪ Confirmation and documentation from your prescribing provider that all preferred therapeutic alternatives were tried for a clinically appropriate duration of treatment and failed to produce a therapeutic response. If the requested exception is for a brand-name prescription drug that has an FDA-approved generic equivalent, your prescribing provider must document your inadequate response to at least two manufacturers of the generic drug, or to all manufacturers of the generic drug if there are fewer than two manufacturers, in addition to all other preferred therapeutic alternatives, before an exception is granted; or ▪ Confirmation and documentation from your prescribing provider that all preferred therapeutic alternatives, including the required number of manufacturers of the same generic prescription drug, caused an adverse drug reaction that prevents you from taking the prescription drug as directed. If the requested exception is for a brand-name prescription drug that has an FDA-approved generic equivalent, your prescribing provider must document your adverse drug reaction to at least two manufacturers of the generic drug, or to all manufacturers of the generic drug if there are fewer than two manufacturers, in addition to all other preferred therapeutic alternatives, before an exception is granted. ALERT! The exception process for noncovered drugs cannot be used for drugs that UMP excludes. For more information about drugs UMP excludes, see the “Prescription drugs and products UMP does not cover” and the “What the plan does not cover” sections. How UMP decides which prescription drugs are preferred Washington State P&T Committee and WSRxS P&T Committee provide recommendations to HCA. WSRxS and HCA review the recommendations and determine which medications are included on the UMP Preferred Drug List, as well as the tier level. The UMP Preferred Drug List includes the committees’ coverage recommendations. Not all prescription drug classes are reviewed by the Washington State P&T Committee. For these prescription drugs, the WSRxS P&T Committee makes coverage recommendations for HCA’s review and final determination of a drug’s coverage. 2024 UMP CDHP (PEBB) Certificate of Coverage 89