Forms & publications

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2017-2018 comparison of UMP monthly premiums

54-510

This document lists the 2017 and 2018 monthly premiums for UMP members who are employees and retirees.

Publication

2018-2019 comparison of UMP monthly premiums

54-510

This document lists the 2018 and 2019 monthly premiums for UMP members who are employees and retirees.

Publication

ABA Therapy Printable Summary 2016

This document summarizes the information on Applied Behavior Analysis (ABA) Therapy coverage available on the UMP website.

Publication

ABA Therapy Services Preauthorization Form

This form is for requesting preauthorization of Applied Behavior Analysis (ABA) Therapy services.

Form

Ardon Health Specialty Drug Release Form

This is a form that members must complete and send with initial order for specialty drugs from the UMP network specialty pharmacy, Ardon Health.

Form

Ardon patient request for non-safety caps on prescription containers

Members can use this form when purchasing specialty drugs through Ardon Health to request that Ardon Health not use child-resistant caps ("safety caps") to package a member's medication.

Form

Ardon PHI Disclosure Authorization Form

15350288

Ardon Health Protected health information disclosure authorization form

Form

Chronic Opioid Attestation form

This form is for provider use. Use of opioids for more than 42 days may be authorized in 12 month intervals when the prescriber signs this attestation form. If a prescriber wants an attestation to be authorized for less than 12 months, the prescriber can include a specific end date on the form.

Form

COE Program brochure

This flyer gives an overview of the Centers of Excellence Program in 2019 for knee and hip replacement and spine care.

Publication

Criteria for Coverage of ABA Therapy Services

Lists criteria for coverage of Applied Behavior Analysis (ABA) Therapy services.

Criteria of coverage

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