Forms & publications

UMP (WSRxS) Prescription drug claim form 2021

This is a Washington State Rx Services (WSRxS) claim form for reimbursement for prescription drugs for Uniform Medical Plan (UMP) members. Members might use this form if they purchased drugs at nonnetwork pharmacies or have other prescription coverage that pays first and UMP is secondary. Members might also use this form if they fail to show their ID at a network pharmacy or get a prescription from a mail-order or internet pharmacy other than Postal Prescription Services.

UMP (WSRxS) Prescription drug claim form 2022

This is a Washington State Rx Services (WSRxS) claim form for reimbursement for prescription drugs for Uniform Medical Plan (UMP) members. Members might use this form if they purchased drugs at nonnetwork pharmacies or have other prescription coverage that pays first and UMP is secondary. Members might also use this form if they fail to show their ID at a network pharmacy or get a prescription from a mail-order or internet pharmacy other than Postal Prescription Services.

UMP (WSRxS) Prescription drug complaints and appeals form

This Washington State Rx Services (WSRxS) form may be included in an appeal or complaint regarding prescription drug coverage, but it 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 documents should be submitted.

UMP Achieve 1 (SEBB) (Regence) Summary of Benefits and Coverage (SBC) 2023

This document puts your health plan benefits for UMP Achieve 1 in a standardized format to help you compare different plans. It includes common services, deductibles, and normal cost shares such as coinsurance and out-of-pocket limits. It also tells you about limits to specific benefits, like a visit or dollar limit for certain services. UMP medical benefits are administered by Regence BlueShield and prescription drug benefits are administered by Washington State Rx Services.

UMP Achieve 1 (SEBB) Certificate of Coverage (COC) 2020

This book describes what is covered under UMP Achieve 1, including medical services and prescription drugs. It describes how to find providers and how much you'll pay to see them (including your deductible, coinsurance, and out-of-pocket limit). Your COC also describes how to request an appeal and how to submit a claim. UMP is administered by Regence BlueShield and Washington State Rx Services (WSRxS) under contract with the Washington State Health Care Authority.

UMP Achieve 1 (SEBB) Certificate of Coverage (COC) 2021

This book describes what is covered under UMP Achieve 1 (SEBB), including medical services and prescription drugs. It describes how to find providers and how much you'll pay to see them (including your deductible, coinsurance, and out-of-pocket limit). Your COC also describes how to request an appeal and how to submit a claim. UMP is administered by Regence BlueShield and Washington State Rx Services (WSRxS) under contract with the Washington State Health Care Authority.

UMP Achieve 1 (SEBB) Certificate of Coverage (COC) 2022

This book describes what is covered under UMP Achieve 1 (SEBB), including medical services and prescription drugs. It describes how to find providers and how much you'll pay to see them (including your deductible, coinsurance, and out-of-pocket limit). Your COC also describes how to request an appeal and how to submit a claim. UMP is administered by Regence BlueShield and Washington State Rx Services (WSRxS) under contract with the Washington State Health Care Authority.

UMP Achieve 1 (SEBB) Certificate of Coverage (COC) 2023

This book describes what is covered under UMP Achieve 1 (SEBB), including medical services and prescription drugs. It describes how to find providers and how much you'll pay to see them (including your deductible, coinsurance, and out-of-pocket limit). Your COC also describes how to request an appeal and how to submit a claim. UMP is administered by Regence BlueShield and Washington State Rx Services (WSRxS) under contract with the Washington State Health Care Authority.