2 B. Amounts exceeding the allowed amount for prescription drugs paid to non-network pharmacies. C. Prescription drugs and products not covered by the plan (see the “Prescription drugs and products UMP does not cover” section). D. Costs for medical services and prescription drugs covered under the medical benefit. See the “Medical out-of-pocket limit” section for how the medical out-of-pocket limit works. What you will pay for after reaching your prescription drug out-of-pocket limit You will still be responsible for paying letters B through D above after you meet your individual prescription drug out-of-pocket limit. Where to buy your prescription drugs ALERT! If you use a non-network retail pharmacy, you will pay the entire cost of the prescription drug at the time of purchase and must submit a claim for reimbursement. However, only the allowed amount for covered drugs will apply to your prescription drug deductible or prescription drug out-of-pocket limit. Prescriptions purchased from an excluded pharmacy are not covered. Pharmacies are contracted through a different network than medical providers. Retail pharmacies WSRxS has a large national network of retail pharmacies, which includes many independent and regional pharmacies in Washington State, as well as national chains. Search for a network pharmacy on the UMP Prescription drug coverage webpage or contact WSRxS Customer Service (see Directory for link and contact information). When you get your prescriptions at a network pharmacy, the pharmacy sends the claim to the plan for you, and you pay only your cost-share (coinsurance and prescription drug deductible) as described in the “What you pay for prescription drugs” section. Covered insulin prescriptions filled at network pharmacies are not subject to your prescription drug deductible. Note: You will pay the entire cost for any prescription drug not covered by the plan, which does not apply to your prescription drug deductible or your prescription drug out-of-pocket limit. 2 Non-network pharmacies may charge more than the allowed amount for prescription drugs. You are responsible for paying this amount in addition to your coinsurance. Prescriptions purchased from an excluded pharmacy are not covered. 96 2024 UMP Select (PEBB) Certificate of Coverage