Limits on drug coverage
This page contains information about programs that may limit your drug coverage.
On this page
Washington State Rx Services may exclude, discontinue, or limit coverage for any drug manufacturer’s version of a drug for any of the following reasons:
- New drugs are developed.
- Generic, biosimilar, interchangeable biosimilar, or follow-on biologic drugs become available.
- A nonprescription alternative, including an over-the-counter alternative becomes available.
- There is a sound medical reason.
- There is lack of scientific evidence a drug is as safe and effective as existing drugs used to treat the same or similar conditions.
- One of the following recommends a change: The Washington State Pharmacy & Therapeutics (P&T) Committee, or Washington State Rx Services.
- A drug receives Food and Drug Administration (FDA) approval for a new use.
- A drug is found to be less than effective by the FDA’s Drug Efficacy Study Implementation (DESI) classifications.
- The FDA denies, withdraws, or limits the approval of a product.
- A more cost-effective alternative is available to treat the same condition.
For approval, the drug must be covered by the plan and be medically necessary for your health condition. Your provider may prescribe a drug or drug dose that is not medically necessary.
You can find out if your drug falls under any of these limits by checking the UMP Preferred Drug List or calling Washington State Rx Services at 1-888-361-1611 (TRS: 711).
Some medications require preauthorization to determine whether they are medically necessary and meet criteria, or the plan will not cover them.
Check the UMP Preferred Drug List to find out if your drug requires preauthorization, or call Washington State Rx Services at 1-888-361-1611 (TRS: 711). You and your prescribing provider can also find the coverage criteria for your drug.
Some examples (not at complete list) of the drugs requiring preauthorization include:
- Certain injectable drugs when purchased through a network retail or mail-order pharmacy.
- Compounded drugs costing more than $150.
If your drug requires preauthorization, your pharmacist or prescribing provider must call 1-888-361-1611 (TRS: 711) 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 (TRS: 711) for details.
Alert: Preauthorization of drug coverage only means that the plan will cover the drug—it does not change the drug’s tier or your coinsurance. You still pay according to the drug’s tier.
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 (TRS: 711).
If Washington State Rx Services denies your request or your provider or pharmacist does not get preauthorization, we will cover the drug only up to the quantity limit amount. You will pay for any extra amount.
Specialty drugs are high-cost injectable, infused, oral, or inhaled drugs or products that need special handling and are subject to special rules. They require preauthorization and are covered only when purchased through the plan's network specialty drug pharmacy, Ardon Health.
You can find out if a drug is a specialty drug by checking the UMP Preferred Drug List or calling Washington State Rx Services 1-888-361-1611 (TRS: 711).
If you are prescribed one, call Ardon Health at 1-855-425-4085. They will provide individualized help to get you the drug you need.
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 have not 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 (TRS: 711) 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 has not been authorized before you get the Step 2 drug.
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.
Tip: If you do not want your drug to be changed, simply ask the pharmacist to fill the prescription as written.
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, or you can tell the pharmacist you want the brand-name or biologic drug. You pay according to the drug's tier as assigned in the UMP Preferred Drug List.
Alert: 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 is not 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.
You can find out if your drug is affected by TIP by checking the UMP Preferred Drug List or calling Washington State Rx Services at 1-888-361-1611 (TRS: 711). 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 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
The pharmacy 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 coinsurance for each extra supply received.
To request a travel override, call Washington State Rx Services at 1-888-361-1611 (TRS: 711).
The plan will not cover a refill until 84 percent of the previous 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, 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.
However, in the event of an emergency or other exigent circumstance, you may request an exception to override the refill too soon policy described above. The plan may require documentation to support your request. Approval of your request is at the sole discretion of the plan.
Washington State Rx Services (network pharmacies)
Online: Your pharmacy account
Business hours: 24 hours a day, 7 days a week
Postal Prescription Services (network mail-order pharmacy)
Online: Your PPS account
Business hours: Monday through Friday 6 a.m. to 6 p.m. and Saturday 9 a.m. to 2 p.m. (Pacific)
Ardon Health (network specialty drug pharmacy)
Business hours: Monday through Friday 8 a.m. to 7 p.m. and Saturday 8 a.m. to noon (Pacific)