How the prescription drug out-of-pocket limit works What applies to this limit The following are 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: • Your prescription drug coinsurance, up to the allowed amount. • Your prescription drug deductible. What does not apply to this limit A. Amounts paid by the plan, including payments for drugs covered in full. 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. 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. 98 2024 UMP Classic (PEBB) Certificate of Coverage