Some products are covered under the preventive care benefit if they: • Are recommended by the U.S. Preventive Services Task Force and the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (see the “Preventive care” benefit); and • Conform to coverage guidelines (see the "How UMP decides which prescription drugs are preferred" section). The brands and types of products covered are limited. For a list of covered preventive care products, check the Preferred Drug List or contact WSRxS Customer Service. You pay $0 if your provider writes you a prescription and you purchase these products from the pharmacy counter at a network pharmacy. If you purchase over-the-counter and send in a paper claim, you may pay part of the cost. Contraceptive drugs and supplies are covered as preventive (see the “Family planning services” benefit for details). See the “Tobacco cessation services” benefit for products covered as preventive for tobacco cessation. Injectable drugs available under the pharmacy benefit Certain injectable drugs may only be available through your pharmacy benefit. You can check the UMP Preferred Drug List to see if an injectable drug is covered through your pharmacy benefit. Some injectable drugs may need to be administered by a health care provider, and these drugs are typically available through your medical benefit. Vaccines administered at network pharmacies may be covered under your pharmacy benefit. Compounded prescription drugs Compounded prescription drugs are the result of combining, mixing, or altering ingredients by a pharmacist in response to a physician’s prescription to create a new drug tailored to the specialized medical needs of an individual member. Traditional compounding typically occurs when an FDA-approved prescription drug is unavailable, or a licensed health care provider decides that an FDA-approved drug is not appropriate for a member’s medical needs. Compounded prescription drugs are covered under Tier 2. There may be additional limits (such as needing preauthorization) for your compound. Contact WSRxS to find out whether a preauthorization is required. Claims for compounded drugs require additional information submitted on the claim form. This information is available from the compounding pharmacy. What you pay for prescription drugs The amount you pay for your prescription drugs depends on the prescription drug’s tier, where you purchase your prescriptions, whether you have met your annual out-of-pocket limit, and for some drugs, whether you have met your deductible. • Prescription drug deductible: $100 per member/$300 maximum for family of three of more • Annual out-pocket-limits: $2,000 per member / $4,000 maximum for family of three of more Tier and Nonspecialty drugs Specialty drugs* description All network pharmacies (retail and mail-order) Preventive • No deductible • No deductible (Preventive)*** • 0% coinsurance • 0% coinsurance Value Tier • No deductible • No deductible (Value) • 0–30-day supply: • 0–30-day supply: 92 2024 UMP Classic (PEBB) Certificate of Coverage