• You need to submit your claim to WSRxS for reimbursement (see the “Submitting a claim for prescription drugs” section). • You do not get the plan discount. • You will pay the difference between the allowed amount and what the pharmacy charges, and it will not apply to your prescription drug deductible or prescription drug out-of-pocket limit. Claims for covered insulins must be submitted to WSRxS for reimbursement before they can apply to your prescription drug deductible. • The plan pays the allowed amount for prescription drugs covered by the plan, whether from a network or non-network retail pharmacy, under the coinsurance percentages as shown in the “What you pay for prescription drugs” section. • The prescription cost-limit (see the “What you pay for prescription drugs” section) does not apply. • Non-network pharmacies will not know if a prescription drug must be preauthorized, has a quantity limit, or has other coverage limits. If you purchase a drug from a non-network pharmacy and limits apply, the plan may not cover or reimburse it. • Prescriptions purchased from an excluded pharmacy will not be covered. See the definition of “Excluded pharmacy.” • Specialty drugs must be purchased from the plan’s network specialty drug pharmacy. See the “Specialty drug” section on page 104. TIP: To submit claims for prescriptions purchased from non-network pharmacies (U.S. retail or international retail pharmacies), see the “Submitting a claim for prescription drugs” section. Prescription drugs purchased outside the U.S. If you purchase prescription drugs outside the U.S. for any reason, the following rules apply: • If the prescription drug is available only by prescription in the U.S. but does not require one outside the U.S., the drug is covered only if prescribed by a provider practicing within their scope of practice. • If you get a prescription drug that is approved for use in another country but not in the U.S., the plan will not cover it. • If you get a prescription drug that is available over-the-counter in the U.S., the plan will not cover the drug, even if you have a prescription from a provider prescribing within their scope of practice. The plan does not cover most over-the-counter drugs. • If you get a prescription drug that is not covered by UMP, the plan will not pay any amount of the cost of the drug. You will be responsible for the full cost of the drug. To submit a claim for a prescription drug purchased at retail pharmacies outside the U.S., see the “Submitting a claim for prescription drugs” section. All necessary information must be included on the prescription drug claim form with drugs and dosage documented. Limits on your prescription drug coverage WSRxS may exclude, not cover, discontinue, or limit coverage for any prescription drug or manufacturer’s version of a drug — or shift a drug to a different tier, or to noncovered or excluded status — for any of the following reasons: • A more cost-effective alternative is available to treat the same condition. 2024 UMP Classic (PEBB) Certificate of Coverage 101