• Prescription drug costs covered by other insurance (see page 123 for coordination with other plans). • Prescription drugs not approved by the FDA. • Prescription drugs prescribed for excluded conditions. • Prescription drugs provided to a member, in whole or in part, while the member is admitted to an inpatient facility. Drugs provided in an inpatient setting are covered under the medical benefit. • Prescription drugs that are not medically necessary. • Prescription drugs that are repackaged. • Prescription drugs that the FDA’s DESI classifications have found to be less than effective. • Prescription drugs under a REMS program required by the FDA when prescribed outside REMS guidelines (see page 100 for details). • Most products considered as a medical device by the FDA. Medical devices may be covered under your medical benefit. The plan also excludes prescription drugs to treat conditions that are not covered under the medical benefit. These include, but are not limited to, prescription drugs for: • Cosmetic purposes. • Fertility or infertility. • Obesity (or weight loss). • Promoting hair growth. • Sexual dysfunction. Limits on plan coverage If you receive a service that is not medically necessary, is experimental or investigational, is listed as an exclusion in the “What the plan does not cover” section, or is listed as a noncovered or excluded prescription drug, you are responsible for paying all associated charges. Preauthorizing medical services ALERT! This section does not apply to prescription drugs. See page 100 for how to request preauthorization of drugs covered under the prescription drug benefit. The plan must preauthorize some medical services and supplies to determine whether the service or supply meets the plan’s medical necessity criteria to be covered. The fact that a service or supply is prescribed or furnished by a provider does not, by itself, make it a medically necessary covered service. Preauthorization is not a guarantee of coverage. A change after the plan has approved a preauthorization request — including, but not limited to, a change of provider or different/additional services — requires your provider to submit a new preauthorization request and for the plan to approve it. If your preauthorization is denied, your provider may request a peer-to-peer review where they can talk to a Regence BlueShield provider about your condition prior to submitting an appeal. For more information contact UMP customer service. 106 2024 UMP Select (PEBB) Certificate of Coverage