ALERT! When a generic equivalent for a brand-name prescription drug becomes available, the brand-name drug immediately becomes noncovered. An exception must be requested and approved for coverage of the brand-name drug if you want to continue using the brand-name drug. Always ask your provider to allow substitution on your prescriptions to save you money. See the “Substitution under Washington State law” section for information on transitioning from a brand-name to generic prescription drug, Requesting an exception for noncovered prescription drugs ALERT! The UMP Preferred Drug List may not show every alternative prescription drug you must try before an exception may be granted. If your exception request is denied, the plan’s response letter will include the reason for the denial and the steps you can take next. If you are prescribed a noncovered drug, and you have tried all the alternative drugs and none are found to be effective, or if the alternatives are found to not be medically appropriate, you or your prescribing provider can request an exception by contacting WSRxS Customer Service. Your prescribing provider can also use CoverMyMeds to request an exception. CoverMyMeds is a free online platform that reviews exception requests from electronic health record systems or directly through the CoverMyMeds portal. To get started, have your provider visit the CoverMyMeds website (see Directory for link). Preferred drug list exceptions and coverage determinations require medical information and are based on medical necessity. Therefore, your prescribing provider must submit clinical information for review and will need to provide WSRxS with the following information: • The prescribing provider’s contact information; • An explanation of why the plan should grant an exception; • An explanation of how the requested medication therapy is evidence-based and generally accepted medical practice; • Documentation of medical necessity for the requested prescription drug over all other preferred therapeutic alternatives (Value Tier, Tier 1, and Tier 2); and • At least one of the following items must also be included with the exception request: ▪ Confirmation and documentation from your prescribing provider that all preferred therapeutic alternatives (Value Tier, Tier 1, and Tier 2) were tried for a clinically appropriate duration of treatment and failed to produce a therapeutic response. If the requested exception is for a brand-name prescription drug that has an FDA-approved generic equivalent, your prescribing provider must document your inadequate response to at least two manufacturers of the generic drug, or to all manufacturers of the generic drug if there are fewer than two manufacturers, in addition to all other preferred therapeutic alternatives before an exception is granted; or ▪ Confirmation and documentation from your prescribing provider that all preferred therapeutic alternatives (Value Tier, Tier 1, and Tier 2), including the required number of manufacturers of the same generic prescription drug, caused an adverse drug reaction that prevents you from taking the prescription drug as directed. If the requested exception is for a brand-name prescription drug that has an FDA-approved generic equivalent, your prescribing provider must document your adverse 2024 UMP Classic (PEBB) Certificate of Coverage 89