How to get the plan discount Be sure to fill your prescriptions at a network pharmacy and show your ID card at the pharmacy counter. If you do, you pay for covered prescription drugs based on the allowed amount (WSRxS’ standard reimbursement). If you do not show your UMP member ID card at a network pharmacy or you use a non- network pharmacy, then you may be charged a higher amount. If the amount charged is more than the UMP allowed amount, you will pay the difference in addition to your coinsurance. Prescriptions purchased from an excluded pharmacy are not covered. If you have more than one insurance plan and UMP is your secondary insurance, show both plan member ID cards at the pharmacy and make sure they know which plan pays first so the pharmacy may bill the plans in the correct order. Non-network pharmacies: Retail You will save money when you buy your prescriptions at network retail pharmacies and network mail- order pharmacies. You may buy your prescriptions (except specialty drugs) at a non-network retail pharmacy, but you will pay more if you do. If you get your prescriptions filled at a non-network retail pharmacy, the following applies: • 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 deductible or out-of-pocket limit. Claims for covered insulins must be submitted to WSRxS for reimbursement before they can apply to your deductible. • What the plan pays is based on the allowed amount for prescription drugs covered by the plan, whether from a network or non-network retail pharmacy. • 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 99. 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. 96 2024 UMP CDHP (PEBB) Certificate of Coverage