What you pay for drugs
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How much you pay depends on the tier of your prescription drug. Find your drug's tier by searching the UMP Preferred Drug List.
You can get up to a 90-day supply for most drugs—except for specialty drugs, which are usually limited to a maximum 30-day supply (depending on the drug).
|Tier||All network pharmacies
Retail and mail-order
|The most you'll pay
Network pharmacies only
|Value Tier||5% coinsurance
|$10—Up to a 30-day supply
$20—31-60 days’ supply
$30—61-90 days’ supply
Select generic drugs
|$25—Up to a 30-day supply
$50—31-60 days’ supply
$75—61-90 days’ supply
|$75—Up to a 30-day supply
$150—31-60 days’ supply
$225—61-90 days’ supply
|Specialty drugs* only—$150
No cost-limit for non-specialty drugs
*Specialty drugs must be purchased through the plan's network specialty pharmacy, Ardon Health.
Tip: Preventive, Value Tier, and Tier 1 drugs do not have a prescription drug deductible. So, if you only get these drugs, you won’t need to pay the deductible.
The prescription drug deductible is $100 per person (maximum of $300 for a family of three or more).
You pay the prescription drug deductible for Tier 2 and Tier 3 drugs. Until you reach your $100 prescription drug deductible, you pay the deductible plus any coinsurance. Once you meet the deductible, you only pay your coinsurance at network pharmacies.
The deductible applies regardless of where you purchase your prescription. For complete information, read the "Prescription drug deductible" section in your certificate of coverage.
This limit controls how much each enrolled person pays for covered prescription drugs and products during a calendar year. It does not limit how much the plan pays.
The prescription drug out-of-pocket limit is $2,000 per person, with no family maximum. Each member must meet their own prescription drug out-of-pocket limit separately.
Your prescription drug deductible and your coinsurance, up to the prescription cost-limit (when it applies), both count toward this limit.
The following do not count toward this limit:
- Amounts paid by the plan, including services covered in full.
- Amounts exceeding the allowed amount for drugs paid to non-network pharmacies. (This is called balance billing.)
- Drugs and products not covered by the plan. See Guidelines for drugs UMP does not cover.
- Costs for medical services, including drugs covered under the medical benefit. (See how the medical out-of-pocket limit works.)
- Costs paid for other enrolled family members’ prescription drugs and products.
You will still be responsible for paying numbers 2-5 above after you meet your individual prescription drug out-of-pocket limit.
After you reach this limit, the plan pays 100 percent of the allowed amount for covered drugs and products. If you receive drugs from a non-network pharmacy that charges more than the allowed amount, you must still pay the difference (balance billing).
You may request an exception to the cost-share (50 percent of the allowed amount) for Tier 3 (nonpreferred) brand-name drugs.
Your prescribing provider must submit clinical information to request preauthorization of an exception. When an exception is approved by the plan, you will pay based on the Tier 2 cost-share (30 percent of the allowed amount, $75 maximum payment per 30-day supply).
For more information, read Requesting preauthorization for an exception to the Tier 3 drug cost share in your certificate of coverage or call Washington State Rx Services at 1-888-361-1611 (TRS 711).
If UMP does not cover a prescription, you may be able get a discount with the Washington Prescription Drug Program (WPDP) Discount Card. All Washington State residents are eligible for a card, and joining the discount card program is free.
To make sure you pay the right amount for your prescriptions, first always show your UMP ID card to the pharmacy. If UMP does not cover the prescription, show your prescription drug discount card to see if you can get a discount.
To learn more about the WPDP Discount Card, including how to enroll, visit Alternate help with prescriptions.
Washington State Rx Services
Business hours: 24 hours a day, 7 days a week