Tier A prescription drug’s tier tells you how much you will have to pay for a covered prescription drug. The UMP prescription drug benefit categorizes covered prescription drugs into four tiers. See the "What you pay for prescription drugs" section for details on the prescription drug tiers. Tobacco cessation services Tobacco cessation services are provided for quitting tobacco use through counseling and nicotine replacement therapy products. Unicompartmental Unicompartmental refers to a diagnosis or procedure affecting only one part, or “component,” of a joint (e.g. knee) as opposed to more than one part of a joint. Uniform Medical Plan Plus–Puget Sound High Value Network (UMP Plus–PSHVN) Uniform Medical Plan Plus–Puget Sound High Value Network (UMP Plus–PSHVN) is a self-insured ACP offered through the PEBB Program and managed by HCA. Value Tier Value Tier refers to cost-effective prescription drugs that are used to treat certain chronic conditions. See the "What you pay for prescription drugs" section for details. Use the UMP Preferred Drug List by visiting hca.wa.gov/ump-pdl to find Value Tier drugs. VSP Choice network provider, vision VSP Choice network provider, vision means an optometrist or ophthalmologist licensed and otherwise qualified to practice vision care and/or provide vision care materials who has contracted with VSP to provide vision care services and/or vision care materials to members. This plan’s provider network is VSP Choice. Disclosures If you need this document in another format or if you need information about how to file a discrimination complaint, read the UMP nondiscrimination and language assistance notice by visiting hca.wa.gov/ump- nondiscrimination. Advice24, Ardon Health, CoverMyMeds, Moda Health, Postal Prescription Services (PPS), Costco Mail- Order Pharmacy, Washington State Rx Services (WSRxS), Premera Blue Cross, and SmartHealth do not provide Blue Cross Blue Shield services and are separate companies solely responsible for their products. VSP is a separate company that provides vision services. Quartet is a separate company that provides assistance accessing behavioral health services. Omada Health is a separate company that provides diabetes prevention program. myStrength is a separate company that provides virtual behavioral health care services. 192 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage