Prescription drugs - SEBB

This page contains benefit information for 2020. For 2021 open enrollment information visit the UMP (SEBB) Open Enrollment webpage.

Prescription drugs

Your prescription drug benefits are managed by Washington State Rx Services, a partnership between Moda Health, Postal Prescription Services (PPS), Ardon Health, and MedImpact Healthcare Systems Inc. These companies provide customer service, claims processing, home delivery, and specialty drugs. Visit the Understanding your coverage section of this website for detailed drug cost and coverage information.

 Prescription drug coverage and cost

There are several factors that determine whether a drug is covered and how much it’ll cost. Use these tools to find out more about the prescription drugs you take.

Is it covered?

Use the UMP Preferred Drug List to find out if a drug:

  • Is covered by your plan
  • Needs pre-authorization
  • Is a specialty drug and must be bought through the plan’s specialty drug pharmacy, Ardon Health
  • Has any limits on coverage
  • Has less expensive alternatives

How much will it cost?

Use the Drug Price Check tool for UMP Achieve 1 , UMP Achieve 2, UMP High Deductible, and UMP Plus to estimate the cost of your drug.

  • If you have UMP Achieve 1 and UMP Achieve 2, the prices for Tier 2 drugs listed assume you’ve met your prescription drug deductible. If you have UMP High Deductible, the prices listed assume you have met your combined (medical and prescription drug) deductible. You will pay the entire cost of prescription drugs until you meet your prescription drug deductible (deductible for UMP High Deductible). Once you have met your deductible for the year, you only pay your coinsurance.

  • If you have UMP Achieve 1, UMP Achieve 2, or UMP Plus, you can request an exception for a noncovered drug by having your prescribing provider request pre-authorization. If the exception is approved, you will pay based on the Tier 2 cost-share.

Drug discount card

If your drug is not covered, you may be able get a discount with the Washington Prescription Drug Program Discount Card. All Washington State residents are eligible for a card, and joining the program is free.

Join the discount card program or learn more about alternate help with prescriptions.

 Network pharmacies

You’ll get the UMP member discount when you buy prescription drugs through one of UMP’s network retail pharmacies, network mail-order pharmacy, or network specialty drug pharmacy. Always show your UMP member ID card at the pharmacy to make sure you pay the right amount. If you have a prescription drug discount card, show that card second to see if you can get a discount on prescriptions UMP does not cover.

If you do not show your plan ID card, you will have to pay the full cash price and submit a Prescription Drug Claim Form. You also will not receive the plan discount.

Use the Pharmacy Locator tool for UMP Achieve 1, UMP Achieve 2, UMP High Deductible, and UMP Plus to find a network pharmacy.

You can purchase your prescriptions (except specialty drugs) at a non-network pharmacy, but you’ll pay more if you do. You don't get the plan discount and you will need to submit your own claim to Washington State Rx Services for reimbursement.

For prescription drugs purchased outside the U.S., contact Washington State Rx Services.

Retail pharmacies

Washington State Rx Services has a large network of retail pharmacies. Not only will you save money when you use a network pharmacy, but the pharmacy will send claims to Washington State Rx Services for you.

Mail-order drugs

Enjoy the convenience of home delivery with Postal Prescription Services (PPS), UMP’s only network mail-order pharmacy. You can order new prescriptions and refills, check order status, manage prescriptions, and track your package. PPS can ship within the U.S. only.

When using PPS, the same cost share, pre-authorization requirements, and limits on coverage apply as for prescription drugs purchased at retail network pharmacies. To learn more, contact Washington State Rx Services or PPS.

Sign up for mail order.

Specialty drugs

Specialty drugs are high-cost injectable, infused, oral, or inhaled prescription drugs or products that require special handling and storage and are subject to additional rules. You may find out if a drug is a specialty drug by checking the UMP Preferred Drug List. These drugs are covered only when purchased through UMP’s network specialty drug pharmacy, Ardon Health. If Ardon Health cannot dispense the drug, they will direct you to another specialty pharmacy that can provide the drug. Contact Washington State Rx Services to learn more.

Get contact information for Ardon Health.

Vaccinating pharmacies

You can get covered, preventive vaccinations at no cost at a network vaccination pharmacy. Not all pharmacies offer vaccinations, so check with the pharmacy before you go. You can also get vaccinations through your preferred or network provider.

To find out which vaccinations are considered preventive, check the Centers for Disease Control (CDC) immunizations schedules. Note that some covered immunizations are classified as “may be recommended” depending on medical condition or lifestyle. For those immunizations to be covered as preventive, you must meet the criteria described on the CDC schedule.

The plan does not cover immunizations for travel or employment, even when recommended by the CDC or required by travel regulations.

 Prescription drug policies

Some policies and programs may limit your prescription drug coverage.

  • Limits on drug coverage Some prescription drugs are not covered by your plan. To be covered, the drug must be on the Preferred Drug List and be medically necessary for your health condition. You can find out if your drug’s coverage is limited by checking the UMP Preferred Drug List or calling Washington State Rx Services.

  • Pre-authorization Some drugs need pre-authorization to determine whether they are medically necessary and meet other criteria, or the plan will not cover them. Find out if your drug needs pre-authorization by calling Washington State Rx Services or checking the UMP Preferred Drug List. You and your prescribing provider can also find the coverage criteria for your drug. If your drug needs pre-authorization, you, your pharmacist, or your provider must call Washington State Rx Services to request it. Drugs covered under the medical benefit rather than the prescription drug benefit have different rules for pre-authorization. Call UMP Customer Service for details.

  • Step therapy When a drug is part of the step therapy program, you must try certain drugs (Step 1) before the Step 2 drug will be covered. To find out if step therapy applies to your drug, check the UMP Preferred Drug List or call Washington State Rx Services.

  • Generic drug substitutions When a brand-name drug has a generic equivalent the pharmacist has to substitute the generic equivalent for the brand-name drug. Your provider may write the prescription “dispense as written” if they want you to get the brand-name drug, or you can tell the pharmacist you want the brand-name drug. However, you’ll likely have to pay more for the brand-name drug than the generic.

  • Therapeutic Interchange Program (TIP) The Washington State Therapeutic Interchange Program (TIP) allows a pharmacist to substitute a "therapeutic alternative" drug for a noncovered drug in certain cases. Therapeutic alternatives are drugs that are chemically different from your prescribed drug but provide the same therapeutic benefit.

  • Travel overrides If you’re planning to travel for an extended period, you can request a travel override up to two weeks before your departure to get an extra supply of prescription drugs by calling Washington State Rx Services. You may request no more than two travel overrides per calendar year, including all travel within or outside the United States.

  • Emergency fills Emergency fill lets you get a limited quantity of certain drugs while the plan processes your pre-authorization request. This option is only available when a delay could result in emergency care, hospital admission, or a serious threat to your health or others in contact with you. To learn more, see the list of emergency prescription drugs or call Washington State Rx Services.

  • Refill too soon The plan will not cover a refill or an emergency fill until 84 percent of the last prescription should be used up. This also applies if your prescription is destroyed, lost, expired, or stolen.

  • Over-the-counter drugs, vitamins and supplements The plan does not cover over-the-counter drugs, vitamins, and supplements , except for a few that are considered preventive. These are indicated with a "PV" in the UMP Preferred Drug List. Some products are also covered as exceptions. To learn more contact Washington State Rx Services.

  • Diabetes care supplies UMP covers most diabetes care supplies under the prescription drug benefit. For example, continuous glucose monitors fall under UMP’s medical benefit and requires pre-authorization by Regence. If a health plan other than UMP pays first, claims for UMP diabetes cares supplies may be paid differently. To learn more, read “Diabetes care supplies” in the List of benefits section found in your plan’s certificate of coverage.

  • Early refill for natural disaster You may request an early refill for your prescription when you need to evacuate for a natural disaster. To request an early refill or to locate pharmacies that remain open near you, call Washington State Rx Services.
  Claims and account

Prescription drug claims

When you use a network pharmacy and show your UMP member ID card, your claims are submitted for you. If you use a non-network pharmacy, don’t show your ID card, or have other drug coverage that pays first, you may need to submit your own prescription drug claim to Washington State Rx Services for reimbursement.

To submit a claim, download the Prescription Drug Claim Form, fill it out, and send it, along with your pharmacy receipts, to:

Washington State Rx Services
Attn: Pharmacy Claims
P.O. Box 40168
Portland, OR 97240-0168
Fax: 1 (800) 207-8235

Your pharmacy account

View your prescription claims history and find forms through Washington State Rx Services. You can also use the Drug Information and Interaction Checker to learn how your prescription and over-the-counter drugs interact with each other.

Go to your pharmacy account.

  Need help?

When you have questions about your prescription drug coverage or need help finding a network pharmacy, contact Washington State Rx Services.

Washington State Rx Services is a separate and independent partnership of companies that provide services but do not provide Regence BlueShield products or services, and are solely responsible for their product or services.