If a network pharmacy (including mail-order or specialty drug) tells you that preauthorization is required, coverage is denied, or quantities are limited, you, your pharmacist, or your prescribing provider may contact WSRxS Customer Service to request a coverage review or preauthorization. If WSRxS denies the coverage request, you have the right to submit an appeal (see the “Complaint and appeal procedures” section). If your provider thinks you need the prescription drug immediately, they may request an expedited review by submitting all clinically relevant information to the plan by phone or fax. An expedited appeal replaces the first and second level appeals. WSRxS will decide on coverage of the prescription drug within 72 hours of the request. In this case, you may choose to purchase a three-day supply at your own expense. Prescription drugs and products UMP does not cover Prescription drugs and products not covered under the prescription drug benefit include, but are not limited to, noncovered prescription drugs and excluded drugs and products. Noncovered prescription drugs • Noncovered prescription drugs are not covered without an approved UMP Preferred Drug List exception request For more information, see the “Noncovered prescription drugs” section on page 86. Excluded drugs and products • Dental preparations, such as rinses and pastes. • Dietary/food supplements, vitamins, minerals, herbal supplements, and medical foods. • Experimental or investigational prescription drugs. • Homeopathic drugs, including FDA-approved prescription products. • Over-the-counter drugs, products containing an over-the-counter drug, or prescription drugs that have a nonprescription alternative, except for the drugs specified under “Exceptions covered” on page 89, or otherwise listed on the UMP Preferred Drug List. Note: Prescription drugs with a nonprescription alternative — including an over-the-counter alternative having similar safety, efficacy, and ingredients — are excluded. • Over-the-counter products not approved by and registered with the FDA. • Prescription drug costs covered by other insurance (see page 121 for coordination with other plans). • Prescription drugs not approved by the FDA. • Prescription drugs prescribed for excluded conditions. • Prescription drugs provided to a member, in whole or in part, while the member is admitted to an inpatient facility. Drugs provided in an inpatient setting are covered under the medical benefit. • Prescription drugs that are not medically necessary. • Prescription drugs that are repackaged. • Prescription drugs that the FDA’s DESI classifications have found to be less than effective. • Prescription drugs under a REMS program required by the FDA when prescribed outside REMS guidelines (see page 98 for details). • Most products considered as a medical device by the FDA. Medical devices may be covered under your medical benefit. 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage 103