• There is lack of scientific evidence that a prescription drug is as safe and effective as existing drugs used to treat the same or similar conditions. • There is new scientific evidence demonstrating a prescription drug has been found to be less safe or effective than existing drugs to treat the same or similar conditions. Using free prescription drug samples does not guarantee coverage or waive requirements for preauthorization, step therapy, quantity limits, day supply limits, or other limitations. Prescription drugs will only be covered if: • They are not excluded by the plan, are listed on the UMP Preferred Drug List, and are medically necessary for your health condition; or • You received an exception to cover a noncovered drug Although your provider may prescribe a prescription drug that is not considered medically necessary, the above conditions must be met in order for a prescription drug to be covered. The plan excludes experimental or investigational prescription drugs. You may be liable for all charges if you receive prescription drugs or products that are determined to be experimental or investigational (see the “What the plan does not cover” section). If you disagree with the plan’s determination, you have the right to an appeal (see the “Complaint and appeal procedures” section for that process). The limits and restrictions described in the “Limits on your prescription drug coverage” section help WSRxS monitor drug usage, safety, and costs. These limits and restrictions may be added or removed from prescription drugs at any time. You may find out if your prescription drug falls under any of these limits and restrictions by checking the UMP Preferred Drug List on the UMP Prescription drug coverage webpage or contacting WSRxS Customer Service (see Directory for link and contact information). Risk Evaluation and Mitigation Strategies (REMS) Risk Evaluation and Mitigation Strategy (REMS) is a drug safety program that the FDA can require for certain prescription drugs with serious safety concerns to help make sure the benefits of the drug outweigh its risks. REMS are designed to reinforce prescription drug use behaviors and actions that support the safe use of that drug. While all drugs have labeling that describe possible risks, only a few prescription drugs require a REMS. REMS are not designed to mitigate all the adverse events of a prescription drug. These are communicated to health care providers in the drug’s prescribing information. Rather, REMS focuses on preventing, monitoring, and/or managing a specific serious risk by informing, educating, and/or reinforcing actions to reduce the frequency and/or severity of the event. If the REMS program is not followed, the plan may not cover the restricted drug. Preauthorizing prescription drugs Preauthorization is a process that helps make sure that prescription drug benefits are administered as designed and that plan members receive a drug therapy that is safe and effective for their conditions, and provides the greatest value. Some prescription drugs require preauthorization to determine whether they are medically necessary and meet all applicable coverage criteria, or the plan will not cover them. You may find out if your prescription drug requires preauthorization by contacting WSRxS Customer Service or checking the UMP Preferred Drug List on the UMP Prescription drug coverage webpage (see the Directory pages at the beginning of this booklet for links and contact information). You and your prescribing provider may also find the coverage criteria for your prescription drug by referring to the Washington State Rx Services (Moda) preauthorization (UMP PEBB Plans) preauthorization requirements on forms and publications at hca.wa.gov/ump-forms-pubs. If your prescription drug requires preauthorization, your pharmacist or prescribing provider may initiate a request through CoverMyMeds, a free online platform that accepts requests from electronic health 100 2024 UMP Select (PEBB) Certificate of Coverage