Tier and Nonspecialty drugs Specialty drugs* description All network pharmacies (retail and mail-order) ▪ 5% coinsurance or $10, whichever ▪ 5% coinsurance or $10, whichever is less is less • 31–60-day supply: ▪ 5% coinsurance or $20, whichever is less • 61–90-day supply: ▪ 5% coinsurance or $30, whichever is less Tier 1 (Tier • No deductible • No deductible 1/Tier 1 • 0–30-day supply: • 0–30-day supply: Specialty) ▪ 10% coinsurance or $25, whichever ▪ 10% coinsurance or $25, whichever Select generic is less is less drugs • 31–60-day supply: ▪ 10% coinsurance or $50, whichever is less • 61–90-day supply: ▪ 10% coinsurance or $75, whichever is less Tier 2 (Tier • Deductible applies • Deductible applies 2/Tier 2 • 0–30-day supply: • 0–30-day supply: Specialty) ▪ 30% coinsurance or $75, whichever ▪ 30% coinsurance or $75, whichever Preferred drugs is less** is less • 31–60-day supply: ▪ 30% coinsurance or $150, whichever is less** • 61–90-day supply: ▪ 30% coinsurance or $225, whichever is less** *Specialty drugs must be purchased from the plan’s network specialty drug pharmacy, except when you are authorized by WSRxS to receive certain drugs that can only be dispensed by certain pharmacies. ** Except for insulins covered at Tier 2. See the UMP Preferred Drug List for cost limits. ***Preventive drugs required under Patient Protection and Affordable Care Act (PPACA) or recommended by the U.S. Preventive Services Task Force and the Advisory Committee on Immunization Practices of the CDC. You may find a prescription drug’s tier by searching the UMP Preferred Drug List on the UMP Prescription drug coverage webpage or by contacting WSRxS Customer Service (see Directory for link and contact 2024 UMP Classic (PEBB) Certificate of Coverage 93