Forms & publications

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Welcome letter for UMP Plus UW Medicine ACN 2019

This letter lists the documents in the UMP Plus UW Medicine ACN welcome packet for 2019 and provides important contact information.

Publication

What you need to know about your UMP prescription drug benefit for benefit year 2018

This is a summary of how prescription drug benefits work for UMP Classic, UMP Plus, and UMP CDHP for benefit year 2018, including what you'll pay for drugs and a partial list of network pharmacies.

Publication

What you need to know about your UMP prescription drug benefit for benefit year 2019

This is a summary of how prescription drug benefits work for UMP Classic, UMP Plus, and UMP CDHP for benefit year 2019, including what you'll pay for drugs and a partial list of network pharmacies.

Publication

What's Changing for UMP in 2017?

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This is a summary of what changed for UMP benefits in 2017.

Publication

Who is eligible to enroll in UMP Plus for 2018 benefit year?

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This one-page flyer explains who is eligible to enroll in UMP Plus for the 2018 benefit year.

Publication

Who is eligible to enroll in UMP Plus for 2019 benefit year?

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This one-page flyer explains who is eligible to enroll in UMP Plus for the 2018 benefit year.

Publication

WSRxS Authorization for Release of Confidential Information

This form is to authorize the use or disclosure of personal health information.

Form

WSRxS 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

WSRxS Complaints and Appeals form

This 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.

Form

WSRxS Multiple Pharmacy Coverage Inquiry Form (Drug Coordination of Benefits)

This form is for notifying the pharmacy benefits manager that you have prescription drug coverage in addition to UMP.

Form

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