Forms & publications

UMP (ArrayRx) Opioid Attestation form

This Uniform Medical Plan (UMP) form is for provider use. This form is required when patients are using opioids chronically or when daily opioid doses reach 120 MME or greater. This form may authorize use for a maximum of 12-months. ArrayRx created this form.

UMP (ArrayRx) Preferred Drug List (PDL) 2025

This document is the 2025 Preferred Drug List (PDL) for the Uniform Medical Plan (UMP). This 2025 PDL will apply to all UMP plans for PEBB and SEBB members. It lists prescription drugs covered by UMP. The prescription drug benefit is administered by ArrayRx.

UMP (ArrayRx) Prescription Drug Claim Form

This is an ArrayRx 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 Costco Mail-Order Pharmacy or Postal Prescription Services.