TIP: If you get a vaccine from an out-of-network provider, make sure that you submit your claim to Regence BlueShield as a medical claim (see the “Submitting a claim for medical services” section). Prescription drug claim forms are available by visiting forms and publications at hca.wa.gov/ump-forms- pubs or by contacting WSRxS Customer Service. Send the completed claim form, along with your pharmacy receipt(s), to: Pharmacy Manual Claims PO Box 999 Appleton, WI 54912-0999 It is a good idea to keep copies of all your paperwork for your records. When you submit a prescription drug claim to WSRxS, the plan pays the claim based on the following rules, no matter where you purchased the drug: • The plan pays based on the allowed amount. If the pharmacy charges you more than the allowed amount, you will pay your usual coinsurance, plus the difference between what the plan paid and the pharmacy’s charge. • The plan pays all prescription drug claims, including non-network retail pharmacies, based on the drug’s tier coinsurance (see the “What you pay for prescription drugs" section). • 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. 124 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage