• If you get a prescription drug that is available over-the-counter in the U.S., the plan will not cover the drug, even if you have a prescription from a provider prescribing within their scope of practice. The plan does not cover most over-the-counter drugs. • If you get a prescription drug that is not covered by UMP, the plan will not pay any amount of the cost of the drug. You will be responsible for the full cost of the drug. To submit a claim for a prescription drug purchased at retail pharmacies outside the U.S., see the “Submitting a claim for prescription drugs” section. All necessary information must be included on the prescription drug claim form with drugs and dosage documented. Limits on your prescription drug coverage WSRxS may exclude, not cover, discontinue, or limit coverage for any prescription drug or manufacturer’s version of a drug — or shift a drug to a different tier, or to noncovered or excluded status — for any of the following reasons: • A more cost-effective alternative is available to treat the same condition. • A nonprescription alternative, including an over-the-counter alternative, becomes available. • A prescription drug receives FDA approval for a new use. • A prescription drug is used off label to treat an indication that is not determined to be medically necessary by WSRxS. • A prescription drug is purchased from an excluded pharmacy. • Generic, biosimilar, interchangeable biosimilar, or follow-on biologic prescription drugs become available. • New prescription drugs are developed. • The FDA denies, withdraws, or limits the approval of a prescription drug. • The FDA’s Drug Efficacy Study Implementation (DESI) classifications finds a prescription drug to be less than effective. • The Washington State P&T Committee or WSRxS recommends a change (see the "How UMP decides which prescription drugs are preferred" section). • There is a sound medical reason. • There is lack of scientific evidence that a prescription drug is as safe and effective as existing drugs used to treat the same or similar conditions. • There is new scientific evidence demonstrating a prescription drug has been found to be less safe or effective than existing drugs to treat the same or similar conditions. Using free prescription drug samples does not guarantee coverage or waive requirements for preauthorization, step therapy, quantity limits, day supply limits, or other limitations. Prescription drugs will only be covered if: • They are not excluded by the plan, are listed on the UMP Preferred Drug List, and are medically necessary for your health condition; or • You received an exception to cover a noncovered drug Although your provider may prescribe a prescription drug that is not considered medically necessary, the above conditions must be met in order for a prescription drug to be covered. 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage 97