Not all prescription drug classes are reviewed by the Washington State P&T Committee. For these prescription drugs, the WSRxS P&T Committee makes coverage recommendations for HCA’s review and final determination of a drug’s tier level. For the plan to cover a prescription drug for you, it must be medically necessary for your health condition. Your provider may prescribe a drug or drug dosage that does not meet the plan’s definition of medically necessary and therefore will not be covered. ALERT! A prescription drug may be noncovered even if no generic equivalent is available. Guidelines for prescription drugs UMP covers To be covered, a prescription drug must meet all of the following: • Is listed on the UMP Preferred Drug List (The Preferred Drug List is subject to change). • Does not have a nonprescription alternative, including an over-the-counter alternative with similar safety, effectiveness, and ingredients. • Has been dispensed from a licensed pharmacy employing licensed, registered pharmacists. • Has been prescribed by a provider with prescribing authority within their scope of license. • Has been reviewed by either the Washington State or WSRxS P&T Committee (see the "How UMP decides which prescription drugs are preferred" section). • Is approved by the FDA. • Is medically necessary. • Is not classified as a vitamin, mineral, dietary supplement, homeopathic drug, or medical food. • Is not a noncovered prescription drug or product, unless an exception is granted. • Is not an excluded prescription drug or product. • May be legally obtained in the U.S. only with a written prescription. • Meets plan coverage criteria. The plan covers FDA-approved prescription drugs for off-label use (prescribed for a use other than its FDA-approved label) only if it is not considered experimental or investigational by WSRxS and is recognized as effective for treatment: • In a standard reference compendium and supported by peer-reviewed clinical evidence; or • In most relevant peer-reviewed medical literature, if not recognized in a standard reference compendium; or • By the federal Secretary of Health and Human Services. Note: The plan may require that you try standard treatment(s) before it covers a prescription drug for off- label use (prescribed for a use other than its FDA-approved label). The plan will not cover any prescription drug when the FDA has determined its use to be unsafe. ALERT! The plan does not cover prescription drugs purchased through mail-order pharmacies located outside the U.S. 88 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage