***Preventive drugs required under Patient Protection and Affordable Care Act (PPACA) or recommended by the U.S. Preventive Services Task Force and the Advisory Committee on Immunization Practices of the CDC. You may find a prescription drug’s tier by searching the UMP Preferred Drug List on the UMP Prescription drug coverage webpage or by contacting WSRxS Customer Service (see Directory for link and contact information). You may purchase up to a 90-day supply for most prescription drugs. For most specialty drugs, you may purchase up to a 30-day supply. To check your cost, use the Drug Price Check tool on the UMP Prescription drug coverage webpage (the prices for drugs listed in this tool assume you have met your prescription drug deductible). Using Value Tier and Tier 1 drugs reduces prescription costs for both you and the plan. Generic drugs, follow-on biologics, and biosimilars have the same active ingredient as their brand-name counterparts and are usually less expensive. Note: You must use UMP’s network mail-order pharmacies to fill mail-order prescriptions. If you use any other mail-order service to fill your prescription drugs, or you purchase them outside of the U.S., the plan will not cover these drugs if UMP is your primary plan. ALERT! When you use network pharmacies, retail or mail-order, you pay based on the prescription drug’s allowed amount, a discounted price negotiated by the plan. If you use a non-network pharmacy, the pharmacy may charge more than the plan’s allowed amount. You will have to pay this additional amount, which does not apply to your prescription drug deductible or out-of-pocket limit. Prescriptions purchased from an excluded pharmacy are not covered. See the definition of “Excluded pharmacy.” Prescription drug deductible Your prescription drug deductible is $250 per member, with a maximum of $750 for a family of three or more members covered under the same account. You pay this deductible to the pharmacy when you purchase a Tier 2 prescription drug (except for covered insulins). TIP: Since you do not pay any deductible for Preventive, Value Tier, Tier 1 drugs or covered insulins, if you only get drugs from these tiers during the year, you will not need to meet your prescription drug deductible. How your deductible works Note: Your medical deductible and prescription drug deductible are separate. You pay your prescription drug deductible for Tier 2 drugs. Until you meet your prescription drug deductible, you pay your deductible plus any applicable coinsurance, up to the cost of the drug. For prescription drugs that cost less than your deductible, you pay the cost of the drug until you meet your prescription drug deductible. Note: If UMP pays second, you must still meet your prescription drug deductible before UMP covers Tier 2 drugs except for covered insulins (see “How COB works with prescription drugs” on page 123). What applies to your deductible The following paid by the member directly or paid on behalf of the member by another person including payments made through a manufacturer drug coupon or other manufacturer discount: 92 2024 UMP Select (PEBB) Certificate of Coverage