Guidelines for Drugs Covered

To be covered, a prescription drug must meet all of the following criteria:

• Can be legally obtained only with a written prescription.
• Does not have an over-the-counter equivalent. (See exceptions below.)
• Is not classified as a vitamin (except as listed below), mineral, dietary supplement, homeopathic drug, or medical food.
• Is approved by the Food and Drug Administration (FDA).

TIP: Prenatal vitamins prescribed during pregnancy must be preauthorized. Have your provider call 1-888-361-1611.

The plan covers the following prescription drugs as exceptions to the above rules:

• Fluoride supplements for prevention of dental caries for children ages 6 months to 18 years.
• Prescription prenatal vitamins (only during pregnancy).

Your pharmacy benefit also includes the following nonprescription drugs and supplies:

• All insulin and diabetic supplies such as blood glucometers, test strips, lancets, and insulin syringes used in the treatment of diabetes (see “How does UMP cover insulin and diabetes care supplies?” for more information).
• Contraceptive devices and drugs (see Family Planning benefit).
• Over-the-counter prenatal vitamins (during pregnancy).
• Other over-the-counter products and prescription drugs with over-the-counter equivalents that are specifically noted in the Washington State Rx Services Preferred Drug List as covered under Tier 1, Tier 2, or Tier 3.

To be covered, the above-listed prescription and non-prescription drugs and supplies must be prescribed by an approved provider type, and must be medically necessary. Drugs and supplies must be dispensed from a licensed pharmacy employing licensed registered pharmacists.

The plan covers FDA-approved drugs used for off-label indications (that is, prescribed for a use other than its FDA-approved label) only if such use is determined to be medically necessary.

The plan will not cover any drug when the FDA has determined its use to be unsafe.