Forms & publications

This is the Vision Service Plan's (VSP reimbursement form for UMP (PEBB) members. UMP (PEBB) stands for Uniform Medical Plan (Public Employees Benefits Board)

This is a summary of how vision benefits work for UMP Classic Medicare with Part D (PDP) (PEBB) for benefit year 2025, including what you'll pay for services and supplies and how to find providers. UMP vision benefits are administered by Vision Service Plan (VSP).

This form is to order prescription drugs from the UMP network mail-order pharmacy, Postal Prescription Services (PPS), which is a member of Washington State Rx Services (WSRxS).

This form directs the Uniform Medical Plan's (UMP) administrator, Regence, to communicate with you about your personal health information (PHI).

This form is for sending in a claim for medical services received internationally for all Uniform Medical Plans (UMP) (Regence).

This form may be included in an appeal or complaint, but is not required. It helps the member include all the necessary information for an appeal or complaint, and it includes the address and fax number where they should be submitted.

This medical claim form to send in a claim for medical services for all Uniform Medical Plans (UMP) (Regence).

This form is to report to Regence if an injury or illness may be covered under a third party. You may need to use this form even if the incident is not subject to third party coverage.

This document is the Medical Preferred Drug List (PDL) for the Uniform Medical Plan (UMP). It lists prescription drugs covered by UMP under the medical benefit administered by Regence. This list applies to both PEBB and SEBB.

This form is to notify Regence that you have additional coverage under another medical plan.