Find the complete list of covered provider types on the UMP website at ump.regence.com/pebb/benefits/providers/covered-providers. Plan Plan, as referred to in this document, means UW ACN: Uniform Medical Plan Plus–UW Medicine Accountable Care Network (UMP Plus–UW Medicine ACN), a self-insured ACP offered by the PEBB Program. In the eligibility sections (see “Eligibility for subscribers and dependents” on page 140). For information about retiree or survivor eligibility see page 155) “plan” may include other plans not sponsored by the PEBB Program. In the “If you have other medical coverage” section, “plan” may mean any health insurance coverage. Preauthorization Preauthorization is plan approval for coverage of specific services, supplies, or prescription drugs before they are provided to the member. Preauthorization is not a guarantee of coverage. If you or your provider do not receive preauthorization for certain medical services or prescription drugs, the plan may deny the claim. See the “Preauthorizing medical services” section for how this works. A list of medical services that require preauthorization is available on the UMP Policies that affect your care webpage or by contacting UMP Customer Service (see Directory for link and contact information). See page 98 for information on prescription drugs that must be preauthorized. Preferred drug A preferred drug is a prescription drug that is listed on the UMP Preferred Drug List and covered under the Preventive, Value Tier, Tier 1, or Tier 2. Preferred Drug List The UMP Preferred Drug List is a list available online that specifies how prescription drugs are covered by the plan. By using this list, you may find out if a prescription drug is covered, how much you will pay, if the drug must be ordered through the plan’s specialty drug pharmacy, and whether the drug has any limitations (such as needing preauthorization or quantity limits; see the ”Limits on your prescription drug coverage” section). Drugs are designated by “tiers”: • Preventive Tier drugs (e.g. contraceptives) cost you $0 • Value Tier are cost-effective prescription drugs for treatment of certain chronic conditions • Tier 1 are primarily generic prescription drugs • Tier 2 are preferred brand-name prescription drugs and some high-cost generic drugs The UMP Preferred Drug List is based on the Washington Preferred Drug List and recommendations by one of the P&T Committees that partner with WSRxS (see the “How UMP decides which prescription drugs are preferred” section for more information). Prenatal Prenatal means during pregnancy. Prescription cost-limit The prescription cost-limit is the most you pay for a Value Tier drug, Tier 1 drug, and Tier 2 drug at a network pharmacy. See the “How the prescription drug cost-limit works” section for more information. 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage 185