through your medical benefit. Vaccines administered at network pharmacies may be covered under your pharmacy benefit. Compounded prescription drugs Compounded prescription drugs are the result of combining, mixing, or altering ingredients by a pharmacist in response to a physician’s prescription to create a new drug tailored to the specialized medical needs of an individual member. Traditional compounding typically occurs when an FDA-approved prescription drug is unavailable, or a licensed health care provider decides that an FDA-approved drug is not appropriate for a member’s medical needs. Compounded prescription drugs are covered under Tier 2. There may be additional limits (such as needing preauthorization) for your compound. Contact WSRxS to find out whether a preauthorization is required. Claims for compounded drugs require additional information submitted on the claim form. This information is available from the compounding pharmacy. What you pay for prescription drugs The amount you pay for your prescription drugs depends on the prescription drug’s tier, where you purchase your prescriptions, and whether you have met your annual out-of-pocket limit. • Prescription drug deductible: This plan does not have a prescription drug deductible. • Annual out-pocket-limits: $2,000 per member / $4,000 maximum for family of three of more Tier and Nonspecialty drugs Specialty drugs* description All network pharmacies (retail and mail-order) Preventive • No deductible • No deductible (Preventive)*** • 0% coinsurance • 0% coinsurance Value Tier • No deductible • No deductible (Value) • 0–30-day supply: • 0–30-day supply: ▪ 5% coinsurance or $10, whichever ▪ 5% coinsurance or $10, whichever is less is less • 31–60-day supply: ▪ 5% coinsurance or $20, whichever is less • 61–90-day supply: ▪ 5% coinsurance or $30, whichever is less Tier 1 (Tier • No deductible • No deductible 1/Tier 1 • 0–30-day supply: • 0–30-day supply: Specialty) ▪ 10% coinsurance or $25, whichever ▪ 10% coinsurance or $25, whichever Select generic is less is less drugs • 31–60-day supply: ▪ 10% coinsurance or $50, whichever is less • 61–90-day supply: 90 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage