What you pay for drugs
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How much you pay for your prescription depends on the drug’s tier and where you purchase it.
Preventive tier drugs (contraceptives) are covered in full. In general, Value Tier and Tier 1 drugs cost you less money than Tier 3, which are the most expensive. Even though Tier 3 drugs are called “nonpreferred,” the plan still covers them, but you pay more.
|Tier||All network pharmacies
(retail and mail-order)
|The most you'll pay
at network pharmacies only
|Preventive Tier||0 percent coinsurance||$0|
|Value Tier||5 percent coinsurance||
$10—Up to a 30-day supply
Select generic drugs
|10 percent coinsurance||
$25—Up to a 30-day supply
|30 percent coinsurance||
$75—Up to a 30-day supply
|50 percent coinsurance||
Specialty drugs* only: $150
*Specialty drugs must be purchased through the plan's network specialty pharmacy, Ardon Health.
What else do I need to know?
- You do not pay a deductible for prescription drugs, and prescription drug costs don’t count toward your medical deductible.
- 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.
- Generic drugs, follow-on biologics, and biosimilars have the same active ingredient as their brand-name counterparts and are usually less expensive. Learn about generic substitution.
This limits how much each member pays for covered prescription drugs and products during a plan calendar year. It does not limit how much the plan pays.
For each person enrolled in UMP Plus, 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.
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.
What counts toward this limit?
Your prescription drug coinsurance up to the prescription cost-limit (see table above), when it applies, counts toward this limit.
What does not count toward this limit?
The following does not count toward the out-of-pocket limit:
- Amounts paid by the plan, including services covered in full.
- Amounts exceeding the allowed amount for drugs paid to non-network pharmacies. (Non-network pharmacies may charge more than the allowed amount for prescription drugs. You are responsible for paying this amount in addition to your coinsurance.)
- Drugs and products not covered by the plan. See "Guidelines for drugs UMP does not cover" in your PSHVN or UW Medicine ACN certificate of coverage.
- 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.
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, call Washington State Rx Services at 1-888-361-1611 (TRS 711) or read “Requesting preauthorization for an exception to the Tier 3 drug cost-share” in your plan’s certificate of coverage:
- UMP Plus Puget Sound High Value Network 2018 Certificate of Coverage
- UMP Plus UW Medicine Accountable Care Network (ACN) 2018 Certificate of Coverage
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: customer service is available 24 hours a day, 7 days a week