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.
Where you purchase your prescriptions also impacts how much you will pay (read Filling your prescriptions for more information).
You may 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: You do not pay any deductible for preventive, Value Tier, and Tier 1 drugs . If you only get these drugs during the year, you will not 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 this deductible to the pharmacy when you purchase a drug to which it applies.
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 applicable coinsurance, up to the cost of the drug. For drugs that cost less than $100, you will pay the cost of the drug, until you have met the $100 prescription drug deductible.
Once you meet the deductible, you only pay your coinsurance at network pharmacies for all tiers except preventive.
For complete information, read the "Prescription drug deductible" section in your certificate of coverage.
This out-of-pocket 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 prescription drug 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 prescription 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 prescription 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 prescription drugs from a non-network pharmacy that charges more than the allowed amount, you must still pay the difference (balance billing).
You or your prescribing provider 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.
If UMP is your primary insurance coverage, always show your UMP ID card at the pharmacy to make sure you pay the right amount for your prescription. If UMP does not cover your prescription, and you have a WPDP Discount Card, show that card at the pharmacy to see if you can get a discount on prescriptions UMP does not cover.
To learn more about the WPDP Discount Card, including how to enroll, visit Alternate help with prescriptions.
Washington State Rx Services
Online: Your pharmacy account
Business hours: 24 hours a day, 7 days a week
Fax (for providers only): 1-855-425-4096
Business hours: Monday through Friday 8 a.m. to 7 p.m. and Saturday 8 a.m. to 12 p.m. (Pacific)