Forms & publications

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.

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

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.

This ArrayRx 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.

ArrayRx Protected health information (PHI) disclosure authorization form for UMP Classic Medicare with Part D (PDP) members.

This is a summary of how prescription drug benefits work for Uniform Medical Plan (UMP) Classic Medicare with Part D (PDP) plan for benefit year 2025, including what you'll pay for prescription drugs. UMP prescription drug benefits are administered by ArrayRx.