Claims reimbursement Most of the time, the plan will pay preferred or participating providers directly. For claims submitted by you or an out-of-network provider, the plan will determine whether to pay you, the provider, or both. For a child covered by a legal qualified medical child support order (see page 120) the plan may pay the child’s custodial parent or legal guardian. Claims determinations The plan will notify you of action taken on a claim within 30 days of the plan receiving it. This 30-day period may be extended by 15 days when action cannot be taken on the claim due to: • Circumstances beyond the plan’s control. Notice will include an explanation why an extension is needed and when the plan expects to act on the claim. • Lack of information. The plan will notify you within the 30-day period that an extension is necessary, with a description of the information needed and why it is needed. Submitting a claim for prescription drugs You may need to submit your own prescription drug claim to WSRxS for reimbursement if you: • Buy prescription drugs at a non-network retail pharmacy. • Fail to show your UMP member ID card at a network pharmacy. • Have other prescription coverage that pays first, and UMP is secondary. TIP: If you get a vaccine from an out-of-network provider, make sure that you submit your claim to Regence BlueShield as a medical claim (see the “Submitting a claim for medical services” section). Prescription drug claim forms are available by visiting forms and publications at hca.wa.gov/ump-forms- pubs or by contacting WSRxS Customer Service. Send the completed claim form, along with your pharmacy receipt(s), to: Pharmacy Manual Claims PO Box 999 Appleton, WI 54912-0999 It is a good idea to keep copies of all your paperwork for your records. When you submit a prescription drug claim to WSRxS, the plan pays the claim based on the following rules, no matter where you purchased the drug: • The plan pays based on the allowed amount. If the pharmacy charges you more than the allowed amount, you will pay your usual coinsurance (and prescription drug deductible if applicable), plus the difference between what the plan paid and the pharmacy’s charge. • The plan pays all prescription drug claims, including non-network retail pharmacies, based on the drug’s tier coinsurance (see the “What you pay for prescription drugs" section). • If your claim exceeds the quantity limit or the maximum days’ supply allowed by the plan, the plan will pay only for the amount of the prescription drug up to the quantity limit or maximum days’ supply. • If you receive a refill before 84 percent of the last supply you received should have been taken, the plan will not pay for it (see the “Refill too soon” section). 126 2024 UMP Select (PEBB) Certificate of Coverage