Limits on drug coverage
This page contains information about programs that may limit your drug coverage.
On this page
The limits described below help us track drug use, safety, and costs. Drugs may be added to any of these programs at any time.
For complete information, including additional limits, read the "Limits on your prescription drug coverage" section in your certificate of coverage.
Some medications require preauthorization to determine whether they are medically necessary and meet criteria, or the plan will not cover them.
You can find out if your drug requires preauthorization by calling Washington State Rx Services at 1-888-361-1611 or by checking the UMP Preferred Drug List. You and your prescribing provider can also find the coverage criteria for your drug.
Some examples (not a complete list) of the drugs requiring preauthorization include:
- Certain injectable drugs when obtained through a retail pharmacy or a network mail-order pharmacy.
- Drugs costing more than $1,500 and compounded drugs costing more than $150.
If your drug requires preauthorization, your pharmacist or provider must call Washington State Rx Services to request it.
Drugs covered under the medical benefit rather than the prescription drug benefit have different rules for preauthorization. Call UMP Customer Service at 1-888-849-3681 for more information.
Emergency fill: A process called emergency fill lets you get a small amount of certain drugs while the plan processes your preauthorization request. This option is only available when a delay could result in emergency care, hospital admission, or a serious threat to your health or others' health. To learn how this works, read the "Emergency Fill" section in your certificate of coverage.
Certain drugs have a quantity limit per prescription (how much or how many you get). If you need more than this limit allows, your pharmacist or prescribing provider must call Washington State Rx Services at 1-888-361-1611.
If Washington State Rx Services denies your request, or your provider or pharmacist does not get preauthorization, UMP will cover the drug only up to the quantity limit amount. You will pay for any extra amount.
Specialty drugs are high-cost drugs that need special handling and have special rules.
If you are prescribed a specialty drug, the UMP specialty drug pharmacy, Ardon Health, at 1-855-425-4085. They will help to get you the drug you need.
Learn about specialty drugs, including how much you'll pay for them, in the "Specialty drugs" section of your certificate of coverage.
When a drug is part of the step therapy program, you have to try certain drugs (Step 1) before the prescribed Step 2 drug will be covered. When a prescription for a step therapy drug is submitted “out of order,” meaning you haven’t first tried the Step 1 drug before submitting a prescription for a Step 2 drug, your prescription will not be covered. When this happens, your provider will need to prescribe the Step 1 drug for you.
If you or your provider feels that you need the Step 2 prescription filled as originally written, without first trying the Step 1 drug, your pharmacist or prescribing provider can call Washington State Rx Services at 1-888-361-1611 and request coverage. You will have to pay the entire cost of the drug if you have not tried the Step 1 drug and coverage hasn’t been authorized before you get the Step 2 drug.
To find out if step therapy applies to your drug, check the UMP Preferred Drug List or call Washington State Rx Services at 1-888-361-1611.
Note: Only network pharmacies will check to see if step therapy applies to your prescription drug. If you get a step therapy drug at a non-network pharmacy, the drug may not be covered.
Substitution under Washington State law
When a brand-name or biological drug has a generic equivalent or interchangeable biosimilar, pharmacists in Washington State must substitute the generic equivalent or interchangeable biosimilar drug for the brand-name or biologic drug.
Your provider may write the prescription "dispense as written" if he or she wants you to get only the prescribed brand-name or biologic drug. You can also tell the pharmacist you want the brand-name or biologic drug, though you will usually pay more for drugs with a generic equivalent.
Note: New generic drugs are released throughout the year. If you want to save money by using generics, ask your provider to allow substitution on your prescriptions, even if a generic drug isn’t available now. That way, when one becomes available, the pharmacist can automatically refill with the generic.
Therapeutic Interchange Program (TIP)
The Washington State Therapeutic Interchange Program (TIP) allows a pharmacist to substitute a therapeutic alternative drug for a nonpreferred brand-name drug (Tier 3) in certain cases. Therapeutic alternatives are drugs that are chemically different from your prescribed drug but provide the same therapeutic benefit.
Check whether your drug is affected by TIP using the UMP Preferred Drug List or by calling Washington State Rx Services at 1-888-361-1611. Not all nonpreferred drugs are affected by TIP.
The pharmacist will substitute the preferred drug when your prescribing provider has “endorsed” the Washington Preferred Drug List, and:
- You are filling your prescription in Washington State or through Postal Prescription Services (PPS).
- Your prescribing provider allows substitution on your prescription.
If you do not want your drug to be changed, simply ask the pharmacist to fill the prescription as written. Regardless of whether you or your prescriber ask the pharmacist to “dispense as written,” if you get the nonpreferred drug, you will pay the higher Tier 3 coinsurance.
How TIP works at the mail-order pharmacy: PPS will contact your provider to request authorization for the substitution. If approved by the provider, you will receive the alternative preferred drug along with a letter of explanation. If the pharmacy cannot get an authorization from your provider within 48 hours, the prescription will be filled as written, and you will be charged the Tier 3 coinsurance.
You may request a travel override to get an extra supply of medications for extended travel. All of the conditions listed below apply.
- You may request a travel override up to two weeks before your departure.
- You may request no more than two travel overrides per calendar year, including all travel within or outside the United States (U.S.):
- Within the U.S., you may request up to a 90-day supply per prescription, or as allowed under that prescription.
- Outside the U.S., you may request up to a 6-month supply per prescription, or as allowed under that prescription.
- Travel overrides will be granted only while you are covered by the plan. If your eligibility is ending, the plan does not cover drugs past the time when your enrollment in the plan ends.
- You will pay applicable charges (deductible and coinsurance) for each extra supply received.
To request a travel override, call Washington State Rx Services at 1-888-361-1611.
The plan will not cover a refill until 84 percent of the prior prescription should be used up. Claims for therapeutic equivalents of the previously prescribed drug will also be denied. This also applies if your prescription is destroyed, lost, expired, or stolen.
For example, if you get a 90-day supply and you try to refill this prescription before 76 days have passed, coverage will be denied.
You can find out if any of these limits apply to your drug by checking the UMP Preferred Drug List or by calling Washington State Rx Services at 1-888-361-1611.
Washington State Rx Services
Business hours: 24 hours a day, 7 days a week
Postal Prescription Services (PPS)
Fax (for providers only): 1-800-723-9023
Business hours: Monday-Friday 6 a.m. to 6 p.m.; Saturday 9 a.m. to 2 p.m. Pacific time