• 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: ▪ 5% coinsurance or $10, whichever ▪ 5% coinsurance or $10, whichever is less is less • 31–60-day supply: ▪ 5% coinsurance or $20, whichever is less • 61–90-day supply: ▪ 5% coinsurance or $30, whichever is less Tier 1 (Tier • No deductible • No deductible 1/Tier 1 • 0–30-day supply: • 0–30-day supply: Specialty) ▪ 10% coinsurance or $25, whichever ▪ 10% coinsurance or $25, whichever Select generic is less is less drugs • 31–60-day supply: ▪ 10% coinsurance or $50, whichever is less • 61–90-day supply: ▪ 10% coinsurance or $75, whichever is less Tier 2 (Tier • Deductible applies • Deductible applies 2/Tier 2 • 0–30-day supply: • 0–30-day supply: Specialty) ▪ 30% coinsurance or $75, whichever ▪ 30% coinsurance or $75, whichever Preferred drugs is less** is less • 31–60-day supply: ▪ 30% coinsurance or $150, whichever is less** • 61–90-day supply: ▪ 30% coinsurance or $225, whichever is less** *Specialty drugs must be purchased from the plan’s network specialty drug pharmacy, except when you are authorized by WSRxS to receive certain drugs that can only be dispensed by certain pharmacies. ** Except for insulins covered at Tier 2. See the UMP Preferred Drug List for cost limits. 2024 UMP Select (PEBB) Certificate of Coverage 91