Policies - PEBB

Policies that affect your care

Learn about UMP policies that may affect your coverage or care.


Pre-authorization means your provider must request a pre-authorization for services on the UMP pre-authorization list. To be covered, some medical services and supplies require pre-authorization by the plan before you receive care to determine whether the service or supply meets the plan’s medical necessity criteria. The fact that a service or supply is prescribed or furnished by a provider does not, by itself, make it a medically necessary covered service.

Pre-authorization allows the plan to review your treatment within the context of any other health issues you may have and to consider the latest scientific research available to manage your condition. Some conditions have a wide range of treatment choices, and some treatments work better than others.

Pre-authorization helps you:

  • Understand your treatment options and any related risks
  • Ensure that you'll have insurance coverage for a procedure, treatment, or service
  • Avoid inappropriate or unnecessary medical treatment
  • Save unnecessary out-of-pocket costs by guiding you to the approved service or vendor

Visit the Claims & appeals page to learn how to appeal the denial of a pre-authorization request before receiving services.

Which medical services require pre-authorization?

Your doctor should know which procedures require pre-authorization and can submit a pre-authorization request on your behalf. If a doctor does not get pre-authorization before treating you, your plan will not cover those costs and the doctor may bill you for that treatment. The plan does not approve or deny pre-authorization for services that are not on the UMP pre-authorization list.

See what services require pre-authorization.

To learn more about pre-authorization for medical services, you can also read the "Limits on plan coverage" section in your plan's certificate of coverage or call UMP Customer Service.

Pre-authorization for prescription drugs

For information on pre-authorization for prescription drugs, contact Washington State Rx Services or check the UMP Preferred Drug List.

To learn more about requesting an exception for noncovered drugs, UMP Classic and UMP Plus members can read the "Requesting an exception for noncovered drugs" section in their plan's certificate of coverage.

How long does pre-authorization take?

You will be notified in writing within 15 calendar days of the plan’s receipt of the pre-authorization request whether it has been approved, denied, or if more information is needed.

If additional information is needed:

  • You are allowed up to 45 calendar days from the date on the letter to submit the information.

  • You will be notified in writing of the determination within 15 calendar days from either the plan’s receipt of the additional information or the end of the 45-day period if no additional information is received.

If you or your doctor believes that waiting for a determination under the standard time frame could place your life, health, or ability to regain maximum function in serious jeopardy, your doctor should notify UMP by phone or fax, as a shorter time limit may apply.

 Pre-authorization changes for 2020

In 2020, there are some new pre-authorization requirements. Pre-authorization is required:

  • For more than six visits per injury or episode of treatment for physical, occupational, and speech therapy.
  • For any elective outpatient home-based (unattended) diagnostic study or a facility-based diagnostic or titration study (free-standing or hospital).
  • For sleep treatment equipment and related supplies.

Pre-authorization is also required for most elective outpatient diagnostic imaging procedures. The following imaging procedures are included:

  • Computed tomography (CT)
  • Computed tomography angiography (CTA)
  • Magnetic resonance imaging (MRI)
  • Magnetic resonance angiography (MRA)
  • Positron emission tomography (PET and PET-CT)
  • Nuclear cardiology
  • Myocardial perfusion imaging (MPI)
  • Blood pool imaging
  • MUGA
  • First pass ventriculography
  • Infarct imaging

How are “pre-authorization” and “plan notification” different?

“Pre-authorization” means your provider must request that UMP cover a service on the UMP pre-authorization list, and the plan sends either an approval or denial of coverage. If services that require pre-authorization are not approved before being provided, coverage may be denied.

“Notification” means that your provider must contact the plan to let us know when you receive services. Notification is usually done by the facility at the time you receive these services.

 Infusion drug site-of-care program

If you receive infusion drugs and have UMP Classic or UMP CDHP, be sure to get treatment at an approved site of care. Approved sites of care can include outpatient hospital facilities, infusion suites, doctor’s offices and home infusion. Infusion drugs must be pre-authorized by the plan before you get treatment.

Call UMP Customer Service for a list of drugs included in the site-of-care program or for help finding an approved site of care near you.

 Health Technology Clinical Committee

The Washington State Health Technology Clinical Committee (HTCC) was created to make coverage determinations for selected health technologies based on the available scientific evidence. The purpose of this committee is to ensure medical treatments and services paid for with state health care dollars are safe and proven effective.

The HTCC is an independent committee of health care practitioners that reviews evidenced-based reports and makes a determination if the state should pay for select medical devices, procedures, or tests.

Under state law, the plan must comply with an HTCC determination. See your plan’s certificate of coverage for a list of HTCC services.

Learn more about the HTCC or see the HTCC’s current and past health technology reviews.

 Clinical policies

Learn about UMP policies for transgender services, ABA services (autism spectrum disorder), and opioids.

 Medical drugs

Some policies and programs may limit your medical drug coverage.

  • Pre-authorization Some medical drugs need pre-authorization to determine whether they are medically necessary and meet clinical criteria, or the plan will not cover them. Find out if your drug needs pre-authorization by calling UMP Customer Service. You and your prescribing provider can also find the coverage criteria for your medical drug online. Note: After finding your medical drug on the coverage criteria list, call UMP Customer Service to verify it is covered by your UMP medical drug benefit. If your drug needs pre-authorization, you, your pharmacist, or your provider may request it by calling UMP Customer Service. Your provider may also submit the request electronically.

  • Medical Preferred Drug List For those conditions with many medical drug treatment options, some drugs may be preferred due to effectiveness or cost. The UMP Medical Preferred Drug List identifies these preferred medical drug options when they exist.

  • Clinical pathways for medical drugs A clinical pathway is a tool used for patient care and education. Regence BlueShield provides clinical pathways to help you manage the different treatment options available between the pharmacy and medical benefits for specific disease types and stages. Use these guides to understand how medical drug coverage may be included as part of your treatment plan for the following diagnoses:
    Multiple sclerosis
    Chronic inflammatory diseases
 Additional resources

Getthefactsrx.com features the Starts with One campaign, which is designed to inform and educate young adults, their parents, and older adults about the dangers of prescription drug misuse and the importance of safe storage, use, and disposal. This campaign is funded by HCA.