Forms & publications

This form directs ArrayRx to communicate with you about your personal health information at the address you select.

This form is for UMP Classic Medicare with Part D (PDP) members to use when authorizing a representative to act on your behalf.

This form is used as a request for Medicare prescription drug coverage. ArrayRx administers all prescription drug coverage for UMP Medicare members.

This form is used for appeals when UMP Medicare members have been denied prescription drug coverage. ArrayRx administers all prescription drug benefits for UMP Medicare members.

This form is for notifying ArrayRx that you have prescription drug coverage in addition to Uniform Medical Plan (UMP).

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.

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.

This ArrayRx document lists all anticipated changes to the UMP Preferred Drug List (PDL) effective January 1, 2025.

This ArrayRx document lists all anticipated changes to the UMP Preferred Drug List (PDL) effective February 1, 2025.

This ArrayRx document lists all anticipated changes to the UMP Preferred Drug List (PDL) effective March 1, 2025.