Limits on your prescription drug coverage ..................................................................................................................... 97 What to do if the plan denies coverage .......................................................................................................................... 102 Prescription drugs and products UMP does not cover ............................................................................................ 103 Limits on plan coverage .............................................................................................................................................................. 104 Preauthorizing medical services ......................................................................................................................................... 104 General information from UMP Customer Service ..................................................................................................... 106 What the plan does not cover .................................................................................................................................................. 106 If you have other medical coverage ...................................................................................................................................... 117 Coordination of benefits ........................................................................................................................................................ 117 Contact UMP and WSRxS ....................................................................................................................................................... 117 Who pays first ............................................................................................................................................................................. 117 Billing and payment: submitting a claim ............................................................................................................................. 122 Submitting a claim for medical services.......................................................................................................................... 122 Submitting a claim for prescription drugs ..................................................................................................................... 123 False claims or statements ..................................................................................................................................................... 124 Complaint and appeal procedures ......................................................................................................................................... 125 What is a complaint (aka: grievance)? ............................................................................................................................. 125 How to submit a complaint (aka: grievance) ................................................................................................................ 125 What is an appeal? .................................................................................................................................................................... 125 The appeals process ................................................................................................................................................................. 126 Complaints about quality of care ....................................................................................................................................... 130 Appeals related to eligibility................................................................................................................................................. 130 Where to send complaints or appeals ............................................................................................................................. 130 When another party is responsible for injury or illness ................................................................................................ 131 Occupational injury or illness (workers’ compensation) claims ........................................................................... 131 Legal rights and responsibilities ......................................................................................................................................... 131 Fees and expenses ..................................................................................................................................................................... 132 Services covered by other insurance ................................................................................................................................ 133 Motor vehicle coverage .......................................................................................................................................................... 133 Future medical expenses ........................................................................................................................................................ 133 General provisions ......................................................................................................................................................................... 133 What you need to know: your rights and responsibilities ...................................................................................... 133 Relationship to Blue Cross and Blue Shield Association .......................................................................................... 137 Right to receive and release needed information ...................................................................................................... 137 Right of recovery ....................................................................................................................................................................... 137 Limitations on liability ............................................................................................................................................................. 137 Governing law ............................................................................................................................................................................. 138 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage 11