• The plan pays all prescription drug claims, including non-network retail pharmacies, based on coinsurance. • If your claim exceeds the quantity limit or the maximum days’ supply allowed by the plan, the plan will pay only for the amount of the prescription drug up to the quantity limit or maximum days’ supply. • If you receive a refill before 84 percent of the last supply you received should have been taken, the plan will not pay for it. (see the “Refill too soon” section). You must submit prescription drug claims within 12 months of purchase. The plan will not pay claims for prescription drugs submitted more than 12 months after purchase or prescription drugs purchased from an excluded pharmacy. See the definition of “Excluded pharmacy.” ALERT! If you do not show your UMP member ID card when purchasing a prescription at a network pharmacy, you will have to pay the full cash price and submit a Prescription Drug Claim Form. You will not receive the plan discount. False claims or statements Neither you nor your provider (or any person acting for you or your provider) may submit a claim for services or supplies that were not received, were resold to another party, or for which you are not expected to pay. In addition, neither you nor any person acting for you may make any false or incomplete statements or any false claims on any document for your plan coverage. The plan may recover any payments or overpayments made because of a false claim or false statement by withholding future claim payments, by suing you, or by other means. False claims may also be crimes. If you represent yourself as being enrolled in this plan when you are not, the plan will deny all claims. If the plan asks you for more information, you will be allowed at least 45 days to provide it. If the plan does not receive the information requested within the time allowed, the plan will deny the claim. Complaint and appeal procedures ALERT! In the following section, UMP refers to the administrative functions for appeals for UMP CDHP. Regence BlueShield handles medical appeals; WSRxS handles appeals involving prescription drugs; and Premera handles appeals for the COE Program. See the “Joint replacement surgery, knees and hips in the Centers of Excellence (COE) Program” and “Spine care in the Centers of Excellence (COE) Program” benefits for more information. VSP handles appeals for routine vision benefits. See “Your routine vision benefits” for more information. Appeals procedures may change during the year if required by federal or Washington State law. What is a complaint (aka: grievance)? A complaint is an oral statement or written document submitted by or on behalf of a member regarding: 124 2024 UMP CDHP (PEBB) Certificate of Coverage