Limits on your prescription drug coverage ..................................................................................................................... 99 What to do if the plan denies coverage .......................................................................................................................... 105 Prescription drugs and products UMP does not cover ............................................................................................ 105 Limits on plan coverage .............................................................................................................................................................. 106 Preauthorizing medical services ......................................................................................................................................... 106 General information from UMP Customer Service ..................................................................................................... 108 What the plan does not cover .................................................................................................................................................. 109 If you have other medical coverage ...................................................................................................................................... 119 Coordination of benefits ........................................................................................................................................................ 119 Contact UMP and WSRxS ....................................................................................................................................................... 120 Who pays first ............................................................................................................................................................................. 120 Billing and payment: submitting a claim ............................................................................................................................. 124 Submitting a claim for medical services.......................................................................................................................... 124 Submitting a claim for prescription drugs ..................................................................................................................... 126 False claims or statements ..................................................................................................................................................... 127 Complaint and appeal procedures ......................................................................................................................................... 127 What is a complaint (aka: grievance)? ............................................................................................................................. 127 How to submit a complaint (aka: grievance) ................................................................................................................ 128 What is an appeal? .................................................................................................................................................................... 128 The appeals process ................................................................................................................................................................. 128 Complaints about quality of care ....................................................................................................................................... 132 Appeals related to eligibility................................................................................................................................................. 133 Where to send complaints or appeals ............................................................................................................................. 133 When another party is responsible for injury or illness ................................................................................................ 133 Occupational injury or illness (workers’ compensation) claims ........................................................................... 133 Legal rights and responsibilities ......................................................................................................................................... 133 Fees and expenses ..................................................................................................................................................................... 135 Services covered by other insurance ................................................................................................................................ 135 Motor vehicle coverage .......................................................................................................................................................... 135 Future medical expenses ........................................................................................................................................................ 135 General provisions ......................................................................................................................................................................... 136 What you need to know: your rights and responsibilities ...................................................................................... 136 Relationship to Blue Cross and Blue Shield Association .......................................................................................... 140 Right to receive and release needed information ...................................................................................................... 140 Right of recovery ....................................................................................................................................................................... 140 Limitations on liability ............................................................................................................................................................. 140 Governing law ............................................................................................................................................................................. 140 2024 UMP Select (PEBB) Certificate of Coverage 11